P - 35500Building
Inspections
763-572-3604
763-502-4977 FAX
DATI
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
SITE ADDRESS 7,�«� ���� �� � �-,
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSUR.ANCE
PERMIT TYPE
TYPE OF WORK:
�
Permit No.:� i
�- -.: �.
�:�; ��. ;�� e� � �
�
A� z�
STATE LICENSE #��i�� V _ _ EXP DATE
STATE BOND # EXP DATE
ADDRESS: � Ti�l / k�'4(;lo N.�� CITY �i�� STATE �� ZIPT��'B
PHONE �G,� �o�i�—Ot—��0� FAX 7�� oF��o �o�.W 6
�INGLE FAMILY
❑ NEW
❑ TWO FAMILY O TOWNHOUSE
�EPLACEMENT
DETAILED DESCRII'TION OF WORK �r/4� �o�d�- ��sc��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED.
$35.50.
BATH SINK/LAV FLOOR DRAINS
BATHTUB GAS P1PING (NEED CITY LIC;
CLOTHES WASHER KITCHEN SINK
� DISHWASHER _ LAUNDRY TRAY
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELAV�. MINIMUM FEE
SHOWER
SWIMivIING POOL
WATER CLOSET
�WATER HEATER (S35)
_ WATER ME'f£R
THIS IS AN APPLICATION FOR A PERMIT NOT VALID LJNTIL PROCESSED
WATER PIPING
WATER SOFTNER (�35)
BACKFLOW PREV. ($15}
FOR IltRIGATION
_ OTHER
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 the � Il wo ch quue review and approv�LQf p� s.
SIGNATURE OF APPLICANT �,���9tv '���J���� PRINT NAME /��rn�/�"s-�.- DATE // �
APPROVAL INSPECTORS STGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977