P - 62701Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE �' IU y
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
[NSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
O OWNEft
NAME:
ADDRESS:
PunNF� �OSj� UIniY n
CITY
Permit N
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STATE� NL I P SS�'I� �
STATE LICENSE # ��' �aCJ� '(�' � ' EXP DATE I� � � ��� Z
STATE BOND # EXP DATE
ADDRESS:I s��� �C�'���� �,�Gt'� CITY� a A�P STATE�`{�3 ZIP`J�?3'
PHONE FAX
,�INGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
.�°FREPLACEMENT
❑ TOWNHOUSE
�
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 FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIP[NG (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
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 f�o a perm and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th se of all� r�ich re ires review and appro 1 of plans. j
SIGNATURE OF APPLICANT PRINT NAME �� � � ` �DATE � I G-"i
APPROVAL INSPECTORS SIG RE _ ;i
% City of Fridley
Building Inspections Department ,
6431 University Avenue NE, Fridley, N�N 55432
763-572-3604
FAX: 763-502-4977