P - 35120Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE i-i-aoii
DATE� /
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
YOUR E-MAIL ADDRESS
� (�Q(�l -.�V-� l� �
❑ OWNER y�CONTRACTOR
ADDRESS:
STATE LICENSE # I Y' `�
STATE BOND #
ADDRESS: � ITY��
PHONE ��p� "'4?7 - 7 � c�2 FAX �
�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW
DE�TAILED
WORK
"S�REPLACEMENT
/�
�
Permit No.:
Received By:
�ate��'s.
� � r �
� STATE ZIP
.
EXP DATE 2
EXP DATE
� YI rl� S STATEih k � ZIP�1
,. ,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$3 .50.
y�jBATH SINK/LAV _FLOOR DRAINS ( SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL � WATER SOFTNER ($35)
� CLOTHES WASHER � KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($ I S)
_ 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 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 appli �ion for a permi nd work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the ' o ork �ch requir iew/�nd approval of plans.
SIGNATURE OF APPLICAN� � A N(C�NAME (i �, n., ,� "� DATE
APPROVALINSPECTORS IG /15! � � t DATE
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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