P - 60280Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY �
763-502-4977 FAX EFFECTTVE 1-1-2012
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SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
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CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
YOUR E-MAIL ADDRESS
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❑ OWNER
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PHONE: �C9j' � �'�'( �� `7.3
Permit
Received By:'V
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STATE LICENSE # C.�4 S�7 �� ��`�m EXP DATE
STATE BOND # EXP DATE
ADDRESS: � � �7 � LJ % � �` ��" �'V� CITY Z C �!1 1'�'Z"�f 1'� STATE�ZIP_ �J � `�
PHONE FAX
PERMIT TYPE I ��GLE FAMILY
TYPE OF WORK: I � ��'�'
DETAILED DESCRIl'TION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�EPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOdR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTEIES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY _4VATER HEATER ($35) FOR IRRIGATION
WATER METER � _ OTf�R
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 work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all 'c �aui�s,Jeview and appro al of plans; t,�_ ` ���-�,_) �
SIGNANRE OF APPLICANT %�'C� PRINT NAME� �' S C`l(��.ic�l �HATE e
APPROVAL IIVSPECTORS SIGNATURE DAT,� ,.��, `
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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