P - 36746Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE i-�-zoi i
DATE / j I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENAIYT
�^
YOUR E-MAIL ADDRESS
❑CONTRACTOR
Permit No.:��l �� "��i'�.�
Received By:;�
Dat�� d � �..i �`7 1 '�'�
�„ �_ _r .n
NAME:_�il-�,.,� ( 5'i"'7 n S k f
ADDRESS: �(p � �-v�� C4�r- � CITY_��J ( � STATEM�.�LIP��
PHONE: `O ( Z '� � 5: 20'i
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #_
LICENSE, BOND AND STATE BOND #_
CERTTFICATE OF ADDRESS:
INSURANCE pHONE
PERMIT TYPE SINGLE FAMILY
TYPE OF WORK: �E�'�'
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
EXP DATE
EXP DATE
. CITY
FAX
Cl TOWNHOUSE
ATE ZIP.
FEES ARE BASED ON $]0.00 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) 3WIMMING POOL WATER SOFTTIER ($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 LTNTIL 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 nd work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c 1 �'? � requires review and approv 1 f plans. � y
SIGNANRE OF APPLICANT PRINT NAME ���t, f,�7 n 3�{ DATE O/�////
APPROVAL INSPECTORS G t --7' r, e�rc
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977