P - 35070Building PLUMBING
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-201]
DATE 5 3 I i
SITE ADDRESS �
THIS APPLICANT [S:
PROPERTY
O W NER/
TENANT
YOUR E-MAIL ADDRESS
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❑ OWNER �ONTRACTOR
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NAME:
ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: S�e�K�Cr4uS Plu�biru� =rtc.
SUBMIT A COPY OF STATE LICENSE #�s$!o'S S EXP DATE Ia1/ $ I,/ I I
YOURSTATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATEOF ADDRESS:IIei� E. �� ST.. STE IOI CITY C�QSRA STATEM� ZIP�5318
itvsuR�vcE PxoNE [qsa) 3C�1- OlaB Fax C9j'3) 3(0!- 340$
PERMIT TYPE
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAM[LY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK,IqS�"��� eX�S��dd WA'�et SO�fGn�r rt bar .StA�
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 WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL � WATER SOFI'NER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 application for a permit and work is n to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all or c whic �ec} iires • iew and approval of plans. .I
SIGNATURE OF APPLICANT PRI}�T AME �qSOh S'�'C�K�rtLt S DATE S!
APPROVAL INSPECTORS SI ATURE . �/1 � DATEG /_
� � `City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977