P - 48021Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE I-1-2011
DATE (°�,// /T/
SITEADDRESS Lp�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
L[CENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
�
Permit No.:
Received By:�1� �
Da��'d: �� � �
YOUR E-MAIL ADDRES3 %�'1C fYIC?GIGiI �������iY�ili , L�D�
OCONTRACTOR
NAME: , Vil /Vl `/!�/ f?61�/
ADDRESS: �1J Ij C�'JQFj6'/L�1 /�Y
PHONE:��,�' �/U— �JU/9
NAME:
STATE LICENSE #
STATE BOND # _
ADDRESS:
PHONE
f6 SINGLE FAMILY
TYPE OF WORK: I� NEW
� TWO FAMILY
E9"REPLACEMENT
CITY �r (1��2t�'
EXPDATE
EXP DATE
C[TY
PAX
❑ TOWNHOUSE
ATE�!UZIP.
STATE ZIP,
� � � � � • � � • . : � � � ,, t, n�.�. �� � � :�i�=�►R� �'�1.It'�
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FiXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINfMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER i� WATER PIPING
BATHTUB GAS P(PING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRR[GATION
WATER METER OTHER
��
TH[S [S AN APPLiCATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and t 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 appliFation for a permit and ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in t���� all wAtk�yyhj equires review and approval of plans. /
SIGNATURE OF APPLICANT __ ����%Y� L'(/ PR1NT NAME: ,LI ii?��i %Ll <�%%� �rc.+�+ DATE �02/2 ///
APPROVALINSPECTORSSIGNATURE� DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 ,
FAX: 763-502-4977