P - 59362Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE�
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
YOUR
❑CONTRACTOR
Permit No.:l.� l L����
Received By:�
r�.,,-e v e,. � a .
OWNER/ pDDRESS: Ce�IS �A/`v/ -� G CITY �' �� 3TATE�IZIP, i
TENANT f�
PHONE: C�'Z � 2��"9�%�
CONTRACTOR xAt�t�:
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: CITY STATE ZIP
1NSURANCE pHONE FAX
PERMIT TYPE
TYPE OF WORK: I � �W
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXT'URES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIIvIlvIING POOL WATER SOFTNER ($35)
CLOTf�S WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �g W`ATER HEATER ($35) � �lSR IR�ICy�,lijglN��
��w,ATER METER /OTHER � , (.1.,� ,
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 rmit and work is not to start without a permit on site• that the work will be ' ac rdance
with the approved plan in the of all .or ;t�ich requires review and approval of�Plans.
SIGNATURE OF APPLICANT .� L- PR1NT NAME TOS/� ✓� G- �-�/'t'aGDATE D Z-
APPROVAL INSPECTORS SIG TURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977