P - 43792Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTlVE I-I-201I
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S(TE ADDRESS � l
THIS APPLiCAN�1S:
OWNER/
TENANT
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
[NSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRES3�
_ -�Y i �ii � Q �.., , �Mltii
OWNER OCONTRACTOR
ADDRESS:�(Ii�S �✓'`t-�ll-n 5�` �i� CITY�
PHONE: ) 2y—�1� i — �pK'¢ `�
STATE LICENSE #_
STATE BOND # _
ADDRESS:
PHONE
❑ SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
� TWO FAMILY
❑ REPLACEMENT
�' i
Permit No.:
•- -�: /1,
� . `���" :: � � � .
EXP DATE
EXP DATE
CITY
_ FAX
❑ TOWNHOUSE �
AT9Ul�'�% ZIP��_
STATE ZIP
.�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE N07'ED. FIXTURES: (1NDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
E35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) _ SWfMMING POOL WATER SOFTNER ($35)
CLOTHES WASNER KITCHEN SJNK WATER CI.OSET BACKFLOW PREV. (a!5)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR [RRIGATION
_ WATER METER � OTHER
TH[S [S 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 Fridiey 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 c^ase o� all work whic1h requires review and apI �oval of pilans. /
SIGNATURE OF APPUCANT �Ca�D� �_ s" `� PRINT NAME 1'KYrn� Lc� ��Ci/ � DATE !(S � � 1 �
APPROVALINSPECTORSSIGNATURE neTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977