P - 36700Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE I-1-2011
, ,� �
DATE
S[TE ADDRESS in �
THIS APPLICANT IS:
PROPERTY N
OWNER/ A
TENANT
�'6WNER
PHONE:
YOUR E-MAIL ADDRESS
❑CONTRACTOR
CfTY
Permit No.:�
Received By: /
Date Rec'd:�.
�
STATE ZIPS r�
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERT'IFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE �
PHONE FAX '
PERMIT TYPE
TYPE OF WORK:
�INGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
V
❑ TWO FAMILY ❑ TOWNHOUSE
�PLACEMENT
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 FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL � WATER SOFTTlER ($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET � BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) � FOR IRR]GAT30N
WATER METER O'fHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work wiil 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 art without a permit on site; that the work will be in accordance
with the approved plan in the asz of 11 o c whi q iires re�ie nd appro�al of plans. �
SIGNATURE OF APPLICANT T NA - f'(n p� Q ��, S��,cY L DATE
APPROVAL INSPECTORS SIGNAT RE � � � _ ,P� DATE ... �5r . .
` City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
'763-572-3604
FAX: 763-502-4977