P - 42114Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE I-1-201I
DA1'E�
SITE ADDRESS� �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
YO N�
O OWNER
NAME:_,
ADDRESS:
PHONE:
CONTRACTOR NAMe: �' u� �
SUBMIT A COPY OF
YOUR STATE STATE LICENSE �
LICENSE, BOND AND STATE BOND #
CERTIFtCATE OF ADDRESS: 3Jc�l
INSURANCE pHONE %C �
PERMIT TYPE SINGLE FAMILY
TYPE OF WORK: � NEW
DETAILED DESCR[PTION OF WORK
YOUR E-MAfL ADDRESS
�5��
�ONTRACTOR
0
L ,
�, r /
Permit No
Received By:
Date Rec'd:
CITY STATE Z1P
EXP DATE /c�/</
EXP DATE
fY �� STATE �l/ZIP,�3�
FAx 7C3 -d�"�-- Q�G
❑ TWO FAMILY ❑ TOWNHOUSE •
�REPLACEMENT
FEES ARE BASEDON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
E35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMiNG POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (SIS)
_ DISHWASHER _ LAUNDRY TRAY �ATER HEATER ($35) FOR IRR[GATION
_ WATER METER _ OTHER
TH[S [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and 1 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 Fridiey and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and wo is n o start without a permit on site; that the work will be in accordance
with the approved plan in the cas o k h' h equir s r ew and appro�v 4f pla s
SIGNATURE OF APPUCANT ��l�pl�pp�yc� ��� DATE U l/
APPROVALINSPECTORSSI NA URE � % ' narF
City of Fridtey
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
2� ZS �