P - 42222/i��OS�
Buiiding PLUMBING
Inspections RESIDENTIAL APFLICATION
763-s�2-3604 CIT� UF FRIDLE�
763-�02-497�' FAX EFFECTIVE 1-1-20t0
DATE YOtJK E-MATL ADDRESS
STfE ADDPESS _
'i'HIS APPLICANT IS:
OWNER/
TENANT
CONTRACTOR
SUBMTf A COPY OF
YOUR STATE
LrcFavs�, sorm A.rm
CERTTFICATE OF
INSURANCE
PERMIT TYPE
r�E a� woRx:
O OWNER J�CONTRACTOR
PHt�NE:
v—��0
Permit No.:
Received By:
Date Rec'd: �
STATE LICENSE # EXP DATE
STATE $OND # EXP D1�'1'E
PHONE /S� 3 `�
1�SINGLE FAMILY
l`
C11VEW
DETAILED DE3CRIPTION OF WORK
❑ TVYO FAMILY
�CEMENT
FAX
C7 TQWNHOUSE
FEES ARE BASEA ON $10.00 PER FIXTU1tE, EXCEPT WHERE NOTED. PIXTURES: (INDICATE TOTAL NiJMBER OF EACIi BELOVY}. MINTMtIM FEE
S35.S0.
BATH SINK/LAV FLOOR DRAINS SHOWEIt WATER PIPINCt
� BATHTUB CiAS PII'ING (NEEA CITY LIC) ' SWIIvIIvIlNC3 POOL WATER SOF1NFdt (S3S)
� CLOTHES WASEiER KITCFIEN SINK WA'I�R CLOSET � BACKFLOW PREV. (S1S)
� DISHWA5F�ER _ LAUNDItY TRAY �WATER HEATER ($35} � FOR IItR2GATI4N
„ WATER METEit _.. O"fHFR
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a piumbing permit and I acknowledge that the informarion above is compiete and acourate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an�pplication far a permit and work is not ta start witi2out a permit on site; that the work will be in accordance
with the approved plan ict the case of all w h'ch requires review and approval of plans.
_ ��._.� :.. -
SIGNA'fURE OF
NAME DATE
City af Fridiey
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977