P - 46277Building PLUMBING
Inspections �i SIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-20ll
DATET I I
SITE ADDRESS �
THIS APPL[CANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
17�i_�uf_MIiIM-'���I
�rE oF woRx:
YOUR E-MAIL ADDRESS
❑ OWNER '�CONTRACTOR
ADDRESS:��
PHONE:_�'Ii
NAME: Z��
STATE LICENSE #_
STATE BOND #
ADDRESS: f-�I�
PHONE � ,7-
'�SINGLE FAMILY
i/
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
CITY
CITY �
FAX
❑ TOWNHOUSE
Permit No.:
Received By:
i����
T�ZIP�
EXP DATE
EXP DATE
STATE_�ZI Z
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 FLOOR DRAINS SH6WER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KTfCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICAT ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I knowl�ge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes o e C(i�'y of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permi work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the e all wo equires review and appro��f�plans�'����
SIGNATURE OF APPLICANT � ., P�T NAME I�/K- ��"�!1'e'�� DATE ��� < �I
APPROVAL INSPECTORS SIGNATURE _�/ 1 ' DA
(� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977