P - 35268Building PLU�MBING
Inspections �SIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-i-2011
DATE O� �
SITE ADDRESS _
THIS APPLICANT 1S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
DETAILED DESCRIP'
� �
� '��YOU E-MAIL ADDRESS _
�/'��� n ) C
❑ OWNER
ADDRESS:
��..�
o N,.is u.,i
r�
Permit No.: ` �'! / �
Received By: L
Date Rec'd: �% �� � �
,; ZLC ,.� ,
STATEI'h wZIP
Nwnn�: .rr �c.� �uw�v � �-a.-�
STATE LICENSE # �� ��� , p� EXP DATE �I � Q� 8 i 1
STATE BOND # EXP DATE � I �Q� � l �
ADDRESS: � wC;ITY �f�� JIO�-C.,� �^STATE 1�^�'ZIP�%
PHONE � �'f C��./� � 9���_ FAX �_�' �o� y H� s 7 a�
FAMILY ❑ TWO FAMILY
O NEW
OF WORK
❑ REPLACEMENT
� TOWNHOUSE
b , ��i,� �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
5.50 , ��
ATH SINK/LAV FLOOR DRAINS SHOWER _�VGATER PIPING
BATHTUB � GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15}
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
��31ATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I ac 1 ge that the information above is complete and accurate; that the work wili be in
conformance with the ordinances and cod s o ridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applic io per rt d rk is not to start without a permit on site; that the work will b in a'cordance
with the approved plan in the c a rk wl requires review and approval of plans. �J
SIGNATURE OF APPLICANT PRINT NAME DATE� /�
APPROVAL INSPECTORS SIGNATURE ,��� DATE
�' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432 ��j
763-572-3604
//5 ;� �s'�
FAX: 763-502-4977