P - 47402Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �•(� . I` YOUR E-MAIL ADDF
SITE ADDRESS S � �( `
THIS APPLICANT IS: ER ❑CONTRACTOR
PROPERTY NAME:� ��� '�/��'
T NANT ADDRESS: — ��r �� _
—��,, CITY
PHONE:
CONTRACTOR N,atvtE:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF �DRESS: CITY
INSURANCE —
PHONE F�
PERMIT TYPE
TYPE OF WORK:
`1�SINGLE FAMILY
�W
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
r.,Pi2.1 �e �
❑ TOWNNOUSE
Permit No.:
Received By:�_
Dat��d � � �� �, � � � �
EXP DATE
EXPDATE
,
STATE ZIP
ATE ZIP
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 SOFTNER ($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET �BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER OTHER
THIS [S 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 will be in
conformance with the ordinances an codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application r 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 case of work which requires �iew and appr a ofp ns.j� , ( /
SIGNATURE OF APPLICANT PRINT NAME ��"1/- � �/� � �\ � `� DATE L� ' I � ' ��
APPROVAL INSPECTORS SIGNATURE . ,, . T.,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977