P - 35813Building
Inspections
763-572-3604
763-502-4977 FAX
DAT]
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-I-2010
YOUR E-MAIL ADDRESS
SITE ADDRESS 7,���� ��s�—' ,C: � �,
THIS APPLICANT IS: ❑ OWNER fp�fJNTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
Permit No.:�—� i��
,• - -. : �
� : c: � i� �,� � , ; , : :
A� z�
PHONE: 7 L 3.-!'� % �L -o �S� �
STATE LICENSE #V��j_ f"�� � EXP DATE
STATE BOND # EXP DATE �
ADDRESS: 3�3l � �Lr4l',�oN ��'1°i CITY �n.�� STATE�� ZIP,��BJ�
PHONE �G,� �o�i�o�--�C�O� FAX 7�,� eF��o ,-o�W 6
�INGLE FAMILY
���
❑ TWO FAMILY ❑ TOWNHOUSE
�EPLACEMENT
DETAILED DESCRLPTION OF WORK �/4L� �'/ srs� ��sG��
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BEIAW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED C1TY LIC) SWIMMING POOL WATER SOFTNER (S35)
CIATI-IES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (SIS}
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IItRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowiedge 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 11 wo ch quue�" review and appro� pl s.�/
SIGNATURE OF APPLICANT ,:2�������� ��i� PRINT NAME / �,�n�[ f�i'�-�.. DATE // �
APPROVAL INSPECTORS SIGNATURE _
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
SCANNED