P - 44541Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECI-rvE �-�-20� �
DATE `-*` ,
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
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M�a�f de
�OWNER
NAME: ��
ADDRESS: l 3 �
PHONE: �r �,
NAME:
STATE LICENSE #_
STATE BOND # _
ADDRESS:
PHONE
� SINGLE FAMILY
❑ NEW
YOUR E-MAIL ADDRESS
%'KCrUY D ✓ �
❑CONTRACTOR
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❑ TWO FAMILY
❑ REPI.ACEMENT
t f� � �� —
CITY r � �
Permit No.
Received By:
� p�� '
L -c � p ya ��k� �Cv..� •
EXP DATE
EXP DATE _
CITY
_ FAX .
� TOWNHOUSE
DETAILED DESCRIPTION OF WORK Wa� A�� �-°e"� �C�'� �%��2'� t
ATE�ZIP�7�'Z
STATE ZIP,
FEES ARE BASED ON $10.00 PER FIXT'URE, EXCEPT WtiERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB ^ GAS PIPING (NEED C[TY LIC) SW(MMING POOL WATER SOFTTIER ($35)
_ CLOTHES WASHER ^ KITCHEN StNK WATER CLOSET $ACKFLOW PREV. ($15)
,_ DISHWASHER _ LAUNDRY TTtAY WATER HEATER ($35) FOR IRRIGATION
y WATER METER _ OTHER
TH1S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowl�dge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and co� f the G�ty of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a p 't "d woric is not to start without a permit on site; that the work will be in a cordance
with the approved plan in the case o all w w ch requires review and approval of p ans. ` �j r
SIGNATURE OF APPLICANT P PRINT NAME UPI.G�r? (' `''e'�' DATE �/,�j /%.�
v City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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