P - 43896Building
Inspections
763-572-3604
763-502-4977 FAX
�r�
SI1'E ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PHONE;
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER
YOUR E-MAIL ADDRESS
Permit No.:
Received By:
CO
STATE LICENSE # � � ! 27'�f ��YI EXP DATE � `� —�Z
STATE BOND # E7CP D TE
ADDRESS: ,�_CITY, G�%�� �/ /4 U STATE ZI£�
PHONE � FAX � LO,��"� �I �'— / �`�yg
SINGLE FAMII.Y
❑ NEW
DETAILED DESCRIPTION OF WORK
O TWO FANIILY ❑ TOWNHOUSE
�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (1NDICATE TOTAL NUMBER OF EACH BELOV�. MINIIo1fIJM FEE
$35.50.
Z BATFiSINK/LAV FLOORDRAAVS SHOWER WATERPIPING
,_ J_ BATHTUB _ GAS PII'ING (NEED CTl'Y LIC) SWIMMINC3 POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KTfCHEN SINK � WATER CLOSET BACKFLOW PREV. (Sl�
_ DI5HWASHER _ LAUNDRY TRAY lWATER HEATER (S35) T FOR Il2RIGATION
_ WATER METER _ OTHER
THIS 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 ' of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicario or a p 't r' not to start without a permit on site; that the work will be in accordance
with the approved plan in the cas�ll wor � h eq ' es iew and apprQ�ral.of plays._ ,_ n�' [ C[e
SIGNATURE OF APPLICANT r PRINT NAME i I�`Y1 �Yl �'nn'rE I a �.2 ��
City of Fridley
Building Iospections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977