P - 37119Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CIT� OF FRIDLE�
763-502-4977 FAX EFFECTivE �-i-ZOio
DATE �,� �=i,"
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTT TYPE
TYPE OF WORK:
� ,.� 5� • �'1r' i
� ❑ OWNER '�CONT:
NAME: �'�,,V �P V�1 i �
ADDRESS: ,
PHONE: �? T��� — ��
NAME: � �1,..�V�� �—��(�
STATE LICENSE #
STATE BOND # `� � �
ADDRESS: ' " � I
PHONE �� ��"-` �
�INGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
Permit No.
Received By:,
ADDRESS
! �°�� 1 V
ciTY � ZV
"_ y'� ,`y`.l 1 �
XP DATE
,�(jy c3 f� � � EXP DATE
�REPLACEMENT
,- ..,
CITY_
FAX
❑ TOWNHOUSE
STATE�ZIP�3�
�
ATE�i' �ZI¢�>z�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (1NDICATE 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
Number of fixtures @ $10.40 x $1Q.00 � $
Number of fixtures @ $15.OQ x $15.00 = $
Nzunber of fixtures @ $35.00 x $35.Q0'= $
State Surcharge $ 5.00
MINIMLIM $40.00 Total = $ � U ��
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 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 appli ti or 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 , of a � h quires review and apprq 1 of plans. ,/
SIGNATURE OF APPLICANT ' PRINT NAME��() I!`� � v-� i� , DATE ��—� ` ��
APPROVAL INSPECTORS SIGNAT '
PLEASE'NO'TE: SEPARATE PERMITS OUIRED FOR �iNG, ELECTRICAL AND MECI-�A1vICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977