P - 48561Building
PLUMBING
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE i-i-aoiz
DATE Z" Z%� I Z+ YOUR E-MAIL ADDRESS
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THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
�,OWNER � ❑CONTRACTOR
Pernut No. � 3 �
Received By:
DatR�jdF �- 2 i1
ADDRESS: i�_�� -_ CITY � Id �� �l STATE�irLIP�3Z
PHONE: � �. � �� �' ���Z•�I
NAME:
STATE LICENSE # EXP DATE
STATE BOND # EXI' DATE
ADDRESS: CITY STATE ZIP
PHONE
�1►SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
j�REPLACEMEN'I'
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 LOOR DRAINS SHOWER � WATER PIPING
BATf-IT'UB �GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTI-�S WASHER � KITCHEN SINK WATER CLOSET ACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY =WATER HEATER (S35) f��IRRIGATION
WATER METER > O R��E«Y �
Nu�pnber of fixtures @ $10.00 � -x $10.00 = $__� �(J i:
Number of fixtures @ $15.00
Number of fixtures @ $35.00
State Surcharge
x $15.00 = $
x$35.00=$
$ 5.00
Tntal = 4.' .��61
���
THiS IS AN APPLICATION FOR A PERNIIT-NOT VALID t7NTIL PROCESSED
/Lt MUtti��Mt
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 t se wor ich requires review and apprr val�of `pl�� � ^�
SIGNATURE OF APPLICAN7' � SL- PRINT NAME ��5 � G� n DATE Z� Z�� I Z
NOTE• SEPARATE PERMITS ARE REQUIRED FOR BUILDING, ELECTRICAL AND MECHA1vICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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