P - 43626Building
Inspections
763-572-3604
7b3-502-4977 FAX
DATE ��� �l ��)
SITE ADDRESS �
TH[S APPLICANT IS
PLUMBING
RESIDEN'I'IAL APPLICA�'ION
��'�'Y 4F FRID�.�Y
EFFECTIVE 1-1-20] 1
" JT
❑ OWNER
PROPERTY NAME:�
OWNER/ ADDRESS:
TENANT
PHONE:
YOUR E-MA1L ADDRESS
�
CITY
Permit No.:
Received By:�
���� .: � d` ��'�
A
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERT'IFICATE OF pDDRESS: �� V ��L � �/ 7Y �1 CITY �/11 � STATE_ 1 ZIP 4
INSURANCE tir-i i n i ir �e T—�lr _ i�__ A �i �,�
PERMIT TYPE
�rE oF woxx:
PHONE ��
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
FAX
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER HITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER , OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LINTIL 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 Conshuction Codes; that I understand this is
not a permit but only an application for a permit and wark is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c s € wor ��� iJich requires review and approv pl /��
SIGNATURE OF APPLICANT ��'"!//� PRINT NAME L ~�'/' DATE I v II
APPROVAL INSPECTORS SIGNATURE ' DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977