P - 36740Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
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SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
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YOUR E-MAIL ADDRESS
❑ OWNER `�ONTRACTOR
ADDRESS:
CONTRACTOR rJA�: (� }-�
SUBMIT A COPY OF —`�'}+t-
YOUR STATE STATE LICENSE #_
LICENSE, BOND AND STATE BOND #_
CERTIF'ICATE OF p�DRESS:_��
INSURANCE pHONE / /- . �] _
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PERMIT TYPE �SINGLE FAMILY
TYPE OF WORK: ���'�'
DETAILED DESCRIPTION OF WORK
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Permit No.�V4�
Received By: �
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STAT'E ZIP_
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❑ TWO FAMILY ❑ TOWNHOUS6
�EPLACEMENT
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BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NO'FED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMUM FEE
BATH SINK/LAV _FLOOR DRAINS
� BATHTUB GAS PTPING (NEED CITY LIC)
CLOTHES WASHER KITCHEN SINK
DISHWASHER LAUNDRY TRAY
SHOWER
SWIlvIMIIVG POOL
WATER CLOSET
WATER HEATER ($35)
WATER METER
WATER PIPING
WATER SOFTNER ($35)
~BACKFLOW PREV. ($IS)
��FOR IItRIGATION
OTI�R
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l�ttYmbcn' of fi�tes @$YO.UO � X S1U.W �$ 0� �
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Number of fiactures @ �15.00 x $15.fl0 = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge $ �.00
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THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowleclge 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 th case of a1 wo hich requires review and approval of pl s. J/ '/
SIGNATURE OF APPLICANT�I�� �4��_�v—��—� PRINT NAME Qf��_DATE `�' ��"�' '�/
APPROVAL INSPECTORS S GNAT[JRE naTF
City of Fridley
Building Inspections Department
b431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-497'7
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