P - 43630Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX FFFF('TNF 1_7_�(111
DATE / C� ' I Li "
SITE ADDRESS ir� ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
PERMIT TYPE
YOUR E-MAIL ADDRESS
❑ OWNER �CON'
NAME: CN �
ADDRESS: �
nvnwTt�. ��w .Z � _ . ���.
Permit No.
Received By:
Dat��d�
�
�
STATE LICENSE # O�,ZI�^LT �I.� �/I�,� EXP DATE (p�"' �l" l��_
STATE BOND # P.�M 1'� t...� EXP DATE
ADDRESS: b'a. � /�.�_G�! r'+ CITY� �r� p K o�. STAT�_ZIP�`��/�yJ
r--...,� �-! � ? ��I� - S� x�-� _ FAX %�Q 3 ^ c""'� 'T-.�.�$�ii 4
TYPE OF WORK: I � �W
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRII'TION OF WORK
❑ REPLACEMENT
G�
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 SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL ` WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15j
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IItRIGATION
_ 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 application for a permit and work is n to start without a permit on site; that the work will be in accordance
with the approved plan in the ca 1 lc whic re uires r iew an pP� al of plans.
SIGNATURE OF APPLICANT PRINT AME 1 E'�d UU �Qr`C.�6.�G2 r^ DATE U^
APPROVAL INSPECTORS SI DA O
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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