P - 48035Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX
EFFECTIVE I-I-201I
DATE�
SITE ADDRESS �
—...
THIS APPLICANT iS�
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
L[CENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
�
R E-MAIL
❑ OWNER [�12CENTRACTOR
NAME:
ADDRESS: CITY
PHONE:
Permit No.: /�t����fL ���'
Received By:�! �
Da���' � � � o � 2 � �
STATE LICENSE # - EXP DATE
STATE BOND # EXP DATE
ADDRESS!���� l�LI y�'L �[d,
PHONE%L �L��r D'"����'�' FAX �r
❑ SINGLE FAMILY O�WO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
C�EPLACEMENT
�[�
ATE_Z1P,
A'
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 DRAfNS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWlMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN S1NK WATER CLOSET BACKFLOW PREV. ($IS)
_ D[SHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR [RRIGATION
WATER METER OTHER
TH[S 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 applicatio r ermi nd wor is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c or e res review and approval o s. ,)/�
SIGNATURE OF APPLICANT PRINT NAME �.. // G DATE %2- I
APPROVAL INSPECTORS SIGN URE ne-rF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977