P - 48653Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `'�' "( `��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNERJ
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
1NSURANCE
PERMIT TYPE
PLUMBING Pe�►it No.:Q��a-o(�� 3
RESIDENTIAL APPLICATION Received By: �� z_1r
CITY OF FRIDLEY ����p � n�� t11
YOUR E-MAIL ADDRESS �"'�'�'
� OWNER •�CONTRACTOR
_ d R • f
f o^-�
ADDRESS: Vi C% CITY STATE ZIP
PHONE:
NAME: rc�� !-��••.ti �`
STATE LICENSE # G�i' 7— � EXP DATE I�-'�ll' ��'
STATE BOND # ��C� EXP DATE I�' �� �� I�
ADDRESS: � Lt �'�1 � 5 C� /'�f CITY �P STATE MN ZIP �7 O lf
PHONE f,�ra -�-� 1- � c;�� FAX
TYPE OF WORK: I � ��'�'
DETAILED DESCRIPTION OF
,�� � ,� w ,�.� �s^
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
�f2EPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINKILAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLO'I'f�S WASHER ?_ZKITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY �ATER HEATER ($35) FOR IRRIGA'fION
WATER METER O'TEIER
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 not to start without a permit on site; that the work will be in accordance
with the approved plan in thgf�e of al] work which requires review and approv 1 of plans.
SIGNANRE OF APPLICANT . � --`"""'�' y�, PRINT NAME w�,' 4 DATE�—�1�_
APPROVAL INSPECTORS SI NATUR � -'""� �" %—DA �
., � _....
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977