P - 35466Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit N
� - - � : �'[!.'.1►�'� 1
-
I� .* T i; � „ '" � � 1�
DATE �j O'tc'�� l 1 YOUR E-MAIL ADDRESS Vc�(Y'j�`�,�T L� `C��ii'��..� � l_.1CSVY1
SITE ADDRESS ��� 1;J1 )`�' 1 S"SC� C7`�(i� � Yi `s� ��
THIS APPLICANT IS: O OWNER ,`�CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
.�
PHONE: �ia - �( a- ���
STATE LICENSE # V J ZS �S�
STATE BOND # � � �
ADDRESS: ,7�.��
PHONE � � � I'" ��� "
SINGLE FAMILY
❑ NEW
❑ TWO FAMILY
�REPLACEMENT
�
EXP DATE
EXP DATE
AT�IP�S�{c..�
CITY `�T �x STATE i!% � ��iLIP�1�
_ FAX ���- a$-� -��G
❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK�'j��CR� �� C�l(�-��Orl b � (��'1�
���� ���
FEES ARE 9ASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.SQ
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. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
�� .
t' v
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 Fridiey 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 the ca all • c w h requires review and app oval of lans. /
SIGNATURE OF APPLICANT PRINT NAME�Y��� DA i3
APPROVAL INSPECTORS SIGN RE /i nAT 9D
(/ City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977