P - 44550Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX
EFFECTIVE 1-1-2011
DATE _ '�J /�
SITE ADDR��T
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
YOUR E-MAIL ADDRESS
❑ OWNER ��fNTRACTOR
ADDRESS:
CONTRACTOR NAME:�
SUBMIT A COPY OF STATE LICENSE #
YOURSTATE -
LICENSB, BOND AND STATE BOND #
CERTIFICATE OF ADDRESS:�,�
INSURANCE
PHONE
PERMIT TYPE GLE FAMILY
TYPE OF WORK: � N��''
DETAILED DESCRIPTION OF WORK
�
❑ TWO FAMILY
��.P ACEMENT
FAX
❑ TOWNHOUSE
Permit No.:
�- - -. :
�,,, ;�. ; ,� '�, ;w-
STATE . ZIP.
�
EXP DATE f_�/`�f/ �//
EXP DATE ��/��//y/
S/„N,�/Z STATE�LIP �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDIGATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
535.50.
BATH SINK2AV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY I,IC) SWIMMING POOL � WATER SOFTTlER ($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET � BACKFLOW PREV. {$15)
DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
� WATER METER OTHER
THIS IS AN AP TION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply f r a plu b g permit an c dge that the information above is complete and accurate; that the work wi11 be in
conformance wi the ord n ces and cod f C ty of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but nly an p'cation for woric is not to start without a permit on site; tha the work will be in accordance
with the approve plan in I w r uires r' and appro al o�f/ p ns. n-
SIGNATURE OF AP LICANT T NAME �V � /r DATE`=��7�'�///
APPROVALINSPE�TORSSI RE neTF "�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Frid(ey, MN 55432
763-572-3604
FAX: 763-502-4977