P - 36946Building PLUIVV�BIN�
Inspections RES�DEN�'I�L APP�,ICATION
763-572-3604 C�T�.' OF FRIDLE�
763-502-4977 FAX EFFECT�vE �-�-zo� i
DATF-, l 2 � �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
YOUR E-MAIL ADDRESS
� Pkw� xl�
❑ OWNER l�'ONTRACTOR
ADDRESS:
STATE LICENSE #
STATE BOND #
ADDRESS:�
PHONE ��J'
PERMIT TYPE I �SINGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
C[TY��
_CITY �h �
FAX �
❑ TOWNHOUSE
Permit N
Received By:
ZIP
EXP DATE
EXP DATE
G7 STATE �� ZIP S Z
FEES ARE BASED ON $]0.00 PER FIX1'URE, 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)
CLOT'I�S WASHER �KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER , LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTEIER
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 wark will be in
conformance with the ordinances and code 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 pe 't and wgJrk is not to start without a permit on site; that the work will be in accordance
with the approved plan in the ��'/:v/l-ll w wh h''uires review and aPPro;'�( o�plan�-
SIGNATURE OF APPLICANT P T NAME /�L (G �� DATE � 2 �
APPROVAL INSPECTORS SIGNATURE , � DATE� /l2 li
" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: ?63-502-4977