P - 47804Building
Inspections
763-572-3604
763-502-4977 FAX
DATE___�
SITE ADD SS 1
THIS APPLICANT IS
PROPERTY
OWNER/
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 1-1-2011
�____,�YOUR E-MAIL ADDRESS
❑ El
NAME: � �
ADDRESS:
PHONE:
NAME:
STATE LICENSE #
STATE BOND # �
ADDRESS:__��
PHONE,���^- �
❑ SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ '1 W0 FAMILY
�KEPLACEMENT
Permit No.:
Received By: �—I (�_
����i�� � � ���
-`'" ' STA
EXP DATE
E PD TE �
_CITY STATI
FAX
❑ TOWNHOUSE
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 FLOOR DRAINS SHOWER
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY �iG�ATER HEATER ($35)
_ WATER METER
_ WATER PIPING
_ WATER SOFTNER ($35)
BACKFLOW PREV. ($]5)
FOR IRRIGATION
_ OTHER
_ . �, z,� w_>_ , �� u._�,,
THIS �S AN APPLICATION FOR A PERMIT-NOT VAL1D 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 ordina es and des o the City of Fridley and with the Minneso a Construction Codes; that I understand this is
not a permit but only an ap ication r a i wor not to start with t a per it o sit�e,; tha t wor will e i accordance
with the approved p]an in t w iew and ap� a. �
SIGNATURE OF APPLICANT PRINT NAM� �
APPROVALINSPECTORS NATURE � E
�: � __
��,l�._ ::� ��C"�`; !``'!"�� iY" :�.�•�.•n�r���i� .�,�..,.;.,.«..r4�_.��� __ ATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977