P - 35357F;}��!�ding
�nspections
763-572-3604
763-502-4977 FAX
DATE lT �� � `- (
SITE ADDRESS
THIS=APPLICANT IS:
PROPERTY N�
OWNER/ AI
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
AILED
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
E-MA[L ADDRESS
❑ OWNER �C'bNTRACTOR
STATE LICENSE #�
STATE BOND # �
ADDRESS:
PHON �-
SINGLE FAMILY
�W
[ON OF WORK
O'fW0 FAMILY
❑ REPLACEMENT
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EXP DATE
EXP DATE
CITY
FAX
❑ TOWNHOUSE
ATE i�Y U ZIP,
01/
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICAT'E TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$ 5.50.
� BA'ii�i SINK/LAV f FLOOR DRAINS SHOWER � WATER PIPING
� BATHTUB _ GAS PIPiNG (NEED CITY L]C) � S WIMMiNG POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET � BACKFLOW PREV. ($15)
_ DISHWASHER � LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
i'HIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pemnit and I acknowledge that the information above is comptete and accurate; that the work will be in
conformance with the ordinances and codes of tfie City of Fridley and with the Minnesota Construction Codes; that I understand ihis is
not a permit but only an application' a pern�it 'nd work is not to start without a permit on site; that the work will be in accordance
with the approved plan i c e of all r h' re uires review and ap 1 f lans. l,, j
SIGNATURE OF APPLICA P INT NAME��f �-IJ� ��DATE ��� � 1
APPROVAL INSPECTORS SI ANATURE �i �1 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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