P - 35316Building PLUMBING
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE7-1-2010
�ATE �2 � G�
SITE ADDRESS �
THIS APPLICANT 1S:
PROPERTY
OWNER/
TENANT
corrrxacTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICAT'E OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
❑ OWNER �CC
yn
NAME:� GGtY]C���1
ADDRESS: �D
PHONE: �=��' S�—
NAME: W
STATE LICENSE #
STATE BOND #
ADDRESS: !1 rL-bD /��/I
PHONE ��'�N'� Z
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
/
CITY
FAX
❑ TOWNHOUSE
Permit No.'
Received By:
A
EXP DATE
EXP DATE
STATE�I ZIP ,%
--L.-.�� �GnQ
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 FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMIvIING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 1 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 th �� �e/� f all c� ich requires review and approv/�of plan
SIGNATUREOFAPPLICANT �L+�`w PRINTNAME /�/� �f�L� DATE �� I CJ
APPROVAL INSPECTORS SIGNATURE
D " R� )
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977