P - 45749Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECT[VE 1-1-2011
DATE
SITE ADD ESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
1NSURANCE
PERMIT TYPE
TYPE OF WORK:
❑ fXWNER
NAME:�j�.
ADDRESS:�
PHONE:�,'.�?
.
NAME:'"����
STATE LICENSE #_
STATE BOND # _
ADDRESS�
PHONE��_
CfSINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
YOU E-MAIL ADDRESS
� ' �
�
IQCrONTRACTOR
7��6/�'"i� �^ CITY,
O TWO FAMILY
�PLACEMENT
FAX
❑ TOWNHOUSE
Permit No.`:�(�" � j' l� �''��'�
Received By:���
Date �q:� , 1 �
1SCl, °
ST
EXP DATE
EXP DATE . ,
'L
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 ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER � LAUNDRY TRAY _WATER HEATER ($35) FOR [RRIGATION
_ WATER METER � OTHER �rQJ
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D UNTIL PROCESSED
I hereby app(y 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 application per ' a o is not to start without �mit on site; t at the work will be in acc rdance
with the approved plan in the case wo ' s review and approva plans. //�
SIGNATURE OF APPLICANT PRINT N DATE � I !/
APPROVAL INSPECTORS SI TURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977