P - 39337Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE v�
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTT TYPE
YOUR E-MAIL ADDRESS
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❑ OWNER �ONTRACTOR
NAME: O �/6 vVI�I
A���ss: � �i� � �i `� " '�� J �._��
PHONE: •' .� � � (� b
NAME: IYVI' � I �LVI
STATE LICENSE #
STATE BON #
ADDRESS: ���V �ia 1 c� � 't" �
n �l ��
PHONE �'�0 �% � �S� � L��I�I
�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW
�EPLACEMENT
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DETAILED DESCRIPTION OF WORK TiY1�t I;I.I(1�'1 �YI
Permit No.:
Received By
�� �� �-
EXP DATE
EXP DATE 7
STATE ZIP JJ �L
FEES ARE BASED ON $10.00 PER 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 1 WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowle e t at the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the C� of ridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a e it an wo is not to start without a permit on site; that the work will be in accordance
with the approved plan in the , e' Il w ' re ires review and appr v 1 of pl � C
SIGNATURE OF APPLICANT � T NAME �C,iL �C�'%G"GY DATE 7� C
APPROVAL INSPECTORS SIGNAT[JRE ✓ � �-DATE
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977