P - 84370Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-5�2-4977 FAX EFFECTIVE i-1-2012
DATE /11'_/ / �
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY NAME: �
OWNER/ pDDRESS:
TENANT
PHONE:
Y-O/UR E-MAIL ADDRESS
/V �
OWNER OCONTRACTOR
� �
CITY
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF ,qDDRESS: CITY_
INSURANCE pHONE FAX
PERMIT TYPE
TYPE OF WORK:
� SINGLE FAMTLY
� NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
Permit No
Received
EXP DATE
EXP DATE
. � ..., i ... ,
�
STA
STATE ZIP
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER Of EACH BELOW).
BATH SINK/LAV FLOOR DRARJS SHOWER WATER PIPMG
BATHTUB GAS PIPiNG (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KTTCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER �THER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L PROCESSED
I hereby apply for a plumbing permit and 1 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 start without a permit on site; that the work �vill be in accordance
with the approved plan in the .�ase o all w_ which requires review and approval�opf�p�lan . ,/
SIGNATURE OF APPLICANT a��. PRINT NAME `.�V�x+�v� �G� Jl (C) V'1Gi DATE � � I Z
APPROVAL INSPECTORS S ATURE T�DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977