P - 48242Building
Inspections
763-572-3604
763-502-4977 FAX
DATE :9"` ,��-'
SITE ADDRESS ��
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE I-1-201I
„ YOUR E-MAIL ADDRESS �/JCJ9 �L eY
❑ OWNER ❑CONTRACTOR
PROPERTY NAME: � G�
OWNER/ ADDRESS:�,
TENANT
PHONE:
CONTRACTOR NAME:�
SUBMIT A COPY OF STATE LICENSE
YOUR STATE
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF pDDRESS:
INSURANCE
PHONE
PERMIT TYPE
TYPE OF WORK: I� NEW
FAMILY
DETAILED DESCR[PTION OF WORK
� j C
on
O TWO FAMILY
� �J ���
Permit�f.:`'�/ —�
Received By�
Date Rec'd:%��
_�� � Y C i STAT�//�JZj�
EXP DATE
EXP DATE
_CITY STATE ZIP
FAX
❑ TOWNHOUSE '
/1N�i' ,t.� , av�'rL .
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBGR OF EACH BELOW). MINIMiJM 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 IRRIGATION
WATER METGR OTHER
THfS [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and t 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 ap i a' n for a p ork is not to s rt without a permit on site; that the work will be in accordance
with the approved plan in th of i ' s review �nd appr v I.pf Ij� n ���+ �
SIGNATURE OF APPLICAN , �� PRfi'NT NA %p�/C� ���/G'/�% DATE
APPROVAL INSPECTORS S ATURE � :.".•' e r� DATE L �'� ,</
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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