P - 45213�,� -- �� � s--
Building PLUMBING - permit Ivo.: �
Inspections RESIDENTIAL APPLICATION Received By�
763-572-3604 CITY OF FRIDLEY Date Rec'd:�
763-502-4977 FAX EFFECTrvE �-�-zo>>
DATE ��.L /(ll
SITE ADDRESS "
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTT TYPE
TYPE OF WORK:
❑ OWNER �
NAME:
ADDRESS: 'f ! I
PHONE: �. � v �
NAME: F�� �"�/ �"
STATE LICENSE #
STATE BOND #
ADDRESS: �"1
PHONE ' ,7 "
Y�SINGLE FAMILY
�-
Ll NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
CITY
� �� �' � CITYJ
�� �j FAX
❑ TWO FAMILY
�JtEPLACEMENT
:lliG�i,1�'1 �� rt,
❑ TOWNHOUSE
TA
/I
EXP DATE
EXP DATE
STATE��ZIP �� �-
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATHSINK/LAV _FLOORDRAINS SHOWER _WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWINIMING POOL WATER SOFTNER ($35)
CLOTHES WASHER HITCHEN 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 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 ardinances and codes of the City of Fridley and ith the Minnesota Construction Codes; that I understand this is
not a permit but only an ap ication for a permit and work is not to art without a permit on site; that the work wil] be in accardance
with the approved plan in t of all wh' quires i� and appr val of pl
SIGNATURE OF APPLICANT <- � WNT NAME [��- DATE �O � ��
APPROVAL INSPECTORS SIGNAI'IJRE _ ' DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977