P - 47802Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 4� � � �
SITE ADDRESS ��� �
THIS APPLICANT 15:
PROPERTY
OWNERI
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTiVE 1-1-20] 1
YOUR E-MAIL ADDRESS
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❑ SINGLE FAMILY
O NEW
DETAILED DESCRIPTION OF WORK
�1 1 W0 FAMILY
LTfZEPLACEMENT
❑ TOWNHOUSE
Permit No.:
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FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICA7'E TOTAL NUMBER OF EACH BELOW). MiNIMUM FEE
$35.50.
_ BATH SINK/LAV FLOOR DRAINS SHOWER
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL — WATER PIPING
_ CLOTHES WASHER KITCHEN SINK — _ WATER SOFTNER ($35)
DISHWASHER — WATER CLOSET BACKFLOW PREV. ($15)
— _ LAUNDRY TRAY L✓CATER HEATER ($35) FOR IRRIGATION
�WATER METER OTHER
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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 co es of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an app � atio a e�t nd + r not to start without a permit on site; that the wor will e in accordance
with the approved plan in t o c 'ew and appr al o /d�~ `%
SIGNATURE OF APPLICANT ° P INT NAME NT (�� �/
APPROVAL INSPECTORS S
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977