P - 45214Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX E�FECTIVE �-�-20�,
�.aTE "I ' � i (
SITE ADDRESS II
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
YOUR E-MAIL ADDRESS
❑ OWNER �GONTRACTOR
N
PHONE.
NAME: !V�'Y �77 NT u
STATE LICENSE #
STATE BOND # /
ADDRESS: t�2- [ G i�✓4��9.� S�" �1,� � nG( CITY�
PHONE �����,�° ����J FAX_
PERMIT TYPE I�SINGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
C�EPLACEMENT
/ \
No.:
Received By:
Date Rec'
�
ZIP
EXP DATE
EXP DATE
STATE�ZIP S.S ��L
���,..�'�i�� Zill�i�
FEES ARE BASED ON $10.00 PEIt FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB ^ GAS PIPING (NEED CITY LIC) SWIMMING POOL � WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
' DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METEK _ OTHER
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 application for a permit and work is not to s without a permit on site; that the work will be in accordance
with the approved plan in � e all w��r �l}t h re uires rev' ,w d approv of plan .-
SIGNATURE OF APPLICANT ��� �' `G� ' NAM /�(���<- ���� DATE �i � � � �
APPROVAL INSPECTORS SIGNATURE r DAT
_" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977