P - 46806Building
Inspections
763-572-3604
763-502-4977 F
DAT'E�
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
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❑ OWNER �ONTRACTOR
ADDRESS:
PHONE:
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND �
CERTIFICATE OF ADDRESS:�
INSURANCE pHONE %G
PERMIT TYPE I �"NGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCR[PTION OF WORK
CITY_
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� TWO FAMILY
�tEPLACEMENT
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❑ TOWNHOUSE
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Permit No.: 7ib��c,��J
Received By:
Date Re���D �L � � �
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STATE ZIp
_ EXP DATE �
_ EXP DATE /
�� � STAT.
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINfMUM FEE
$35.50.
_ BATH SINK/LAV FLOOR DRAINS SHOWER
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMMG POOL — WATER PIPING
_ CLOTHES WASHER KtTCHEN S1NK — _. WATER SOFTNER ($35)
DISHWASHER — _ WATER CLOSET BACKFLOW PREV. ($IS)
— _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRlGATION
����.����� _ WATER METER �6THER
`—' TH[S IS AN APPUCATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and f 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 1 understand this is
not a permit but only an applicatio 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 ca f all work
SIGNATURE OF APPLICANT � ---� requires review and approv/�� of lans. /
APPROVAL INSPECTORS SIGNATURE ��'��RINT NAME {� �S ��' iI/i�"���DATE j` I7 I
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977