P - 41786Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-I-2011
DATE d v b 1 YOUR E-MAIL ADDRESS
SITE ADDRESS ��� � �l: i
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TI'PE
TYPE OF WORK:
ADDRESS: CITY
PHONE: K03 ' �'� — ��1 �a"
STATE LICENSE #
STATE BOND # �
ADDRESS:�
PHONE ��n �r
SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
Permit No.
Received By: � '
Date Rec'd: S' I �
ATE ZiP,
EXP DATE
EXP DATE
fY_�C�� ��� STATE ZIP� �
FAX
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (1NDICATE TOTAL NUMBER OF EACH BELO ). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER ATER PIPING
BATHTUB GAS PIPING (NEED C[TY LIC) SWIMMING POOL WATER SOFTTIER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
I hereby apply for a plum
conformance with the ord
not a permit but only an �
with the approved plan in
SIGNATURE OF APPLICANT
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
ing e it an I acknowledge that the information above is complete and accurate; that the work will be in
ian e an ode of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
�plj"c'a io a it work is not to start w' ut a p mit on site; that the work will be in accordance
`e/�'� 1 ' s review and app f pl /� �
�" PRINT NAME (� � DATE �,�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977