P - 45290Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3b04 CITY OF FRIDLEY
763-502-4977 FAX EFFEC�nvE �-�-zo� i
DATE U...-`� �,
SITE ADDRESS t
THIS APPLICANT I3:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
YOUR E-MAIL ADDRESS
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❑ OWNER NTRACTOR
Permit No.;r�%� " �%
Received By; �
Date Rec'd: � ��
�1 c �'�,o. � � c'G�m
NAME:
ADDRESS: CITY STATE ZIP
PHONE:
NAME: `,^,*n' ' ^' �
STATE LICENSE # 'r� � �, % � EXP DATE
STATE BOND # EXP DATE
ADDRESS:� �_� CITY Z-`vvl,vi,.�.�,,,,ya✓1 STATE/,b✓�1P�
PHONE �o � z' ' � � FAX
PERMIT TYPE �SINGLE FAMILY
TYPE OF WORK: I� NEW
DETAI�L`ED�ESCRIPT�O�)NCOF
t � � "'1
❑ TWO FAMILY
PLACEMENT
�� L
❑ TOWNHOUSE
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FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MiNIMUM FEE
�35.50.
t�iBATH SINK/LAV FLOOR DRAINS � SHOWER L WATER PIPING
� BATHTUB GAS PIPING (NEED C[TY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK �WATER CLOSET �BACKFLOW PREV. ($1S)
� DISHWASHER � LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS [S AN APPLICATION FOR j PERM[T-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I ac wfedge t at he information above is complete and accurate; that the work will be in
conformance with the ordinances and codes o e GiY� of r c�1ey and with Construction Codes; that I understand this is
_ ___....._--
not a permit but only an application f r a pe ' �t-a-p�rrriit on site; that the work will be in accordance
with the approved plan in the case of al or ich requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME DATE �, ,�
APPROVAL INSPECTORS SIGNATURE �/1 naTF���
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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