P - 37484Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE�(��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTT TYPE
TYPE OF WORK:
❑ OWNER
NAME:,� ����
ADD�ss: �l D
PHONE:�
NAME:�
STATE LICENSE #_
STATE BON #
ADDRESS: Z (V
PHONE �I? �"J '
'�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
E-MAIL ADDRESS
O TWO FAMILY
�REPLACEMENT
CITY
Permit No.: � � ��i
Received By:
Date �¢zp�t
A'
EXP DATE
EXP DATE
fY� STAT 4 ZIP � rL
FAX � �' � ' ����
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
, DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATBR METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL PROCESSED
I hereby apply for a plumbing permit and acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes the ' Fridiey and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permi d wo k is not to start without a permit on site; that the work will be in accordance
with the approved plan in th e-o all w � req ires review and appro 10 .�j� 1�`
SIGNATURE OF APPLICANT NAME�! ^� (.4'f � � DATE� G�
APPROVAL INSPECTORS SIGNATURE � DATE S /
`� v City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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