P - 42765Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY �:e�=
�ArE �;-'�.�' 1 \
SITE ADDRESS 1 � il� �, �� _�
THIS APPLICANT IS: ❑ OWNER
E-MAIL ADDRESS
PROPERTY NAME: �UYY1 ' i C�]G'cII� CL�u'�n(�� �,(
OWNER/ �D�SS: �jCt.l`nE'� CITY 1^(1
TENANT pxorrE: ��p "�° �"� �— �(O �1
Permit No.:
Received
�iate Rec;'
CONTRACTOR NAME: ��p�j�n �iu�nbin�
SUBMIT A COPY OF STATE LICENSE # �' 61 /'7O-PM EXP DATE I 2-� I I
YOUR STATE
LicErrsE, BorrD AND sTaTE BorrD � 651-365-134f� E� DATE
CERTIFICATE OF ADDRESS: � ' CITY STATE ZIP
INSURANCE pHONE ' FAX
PERMIT TYPE
TYPE OF WORK:
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
❑ TOWNHOUSE
S
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/I.AV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($I S)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IItRIGATION
_ WATER METER _ OTEIER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; 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 application for a permit and rk is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of work w� h �' • • view and approvta�l...o�f� �pl�a�ns.
SIGNATURE OF APPLICANT .� NAME �.X.trYrt�� ��� n/bATE � I'
..,,,n.,.,.. ,,..�„r,.T,,,,� �r,-,.�,T, _ � ,
'" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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