P - 35180Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE i-i-aoii
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SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER ❑CON"I'RACTOR
.
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Permit No.: � ' � �
Received By:
Date Rec' d: � � �
Z�.�'�3�—
STATE LICENSE # S SD �i-'�-f' �M EXP DATE �� -� I� I I
STATE BOND # EXP DATE
.a,DD�ss: l055�3 i/✓�°_ � c���(l�r�,arQ,v�h STATE/�1/_z���'�-�
PHONE�osi-� 7�- a ��a F�
0 SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
� TWO FAMILY D TOWNHOUSE
❑ REPLACEMENT
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. PIX1'URES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MIl�iIMUM FEE
535.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PII'ING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFINER (S35)
CLOTHF.S WASHER � KTI'CHEN SINK ATER CLOSET BACKFLOW PREV. {$15)
_ DISHWASHER _ LAUNDRY TRAY �ATER HEATER (�35) FOR IRRIGATION
_ WATER METER _ OTf�R
�l�b� il��S {� �i�,�i X �►1�f.t� �'� � '� � ��, 77 �; . �,�
Aiumber of fixtures a� $15.U4 x 515.00 =$ �'�
N�ber of fixUires @ $35.00 x $35.00 = $�,����
Sts�e S�rcharge $�5.00
(M1NIlI�IUM 540.00) Tota1= $
� :
I hereby apply for a plumbing
conformance with the ordinanc
not a pennit but only an a ii
with the approved plan ' th
SIGNATL7RE OF APPLI
APPROVAL INSPEC N
PLEA�E N(`)T'E: SEP'AR
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
m� acknowledge that the information above is complete and accurate; that the work will be in
and c es of th ity Fridley and with the Minnesota Construction Codes; that I understand this is
� or a pe ' is not to start without a permit on site; that the work will be in accordance
o ich r ' es review and appr val qf plans.
_ . PA�'TNnME-�far/�y N. Lt1�,9V�r DA� �- -I �t'- I I
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977