P - 44346Building PLUMBING Permit No.:� ������
Inspections RESIDENTIAL APPLICATION Re�ei�ect By:
763-572-3604 CITY OF FRIDLEY I�Q����d:. ��"�
763-5�2-4977 FAX EFFECTIVE 7-1-2010
DATE-�
SITE ADDRESS I
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
E-MAIL
❑ OWNER ❑CONTRACTOR
ADDRESS:
STATE LICENSE #_
STATE BOND # _
ADDRESS.S���
PHONE �% L � —
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
0 TWO FAMILY
�REPLACEMENT
CITY
EXP DATE
EXP DATE
�. � �i
, FAX
❑ TOWNHOUSE
STATE ZIP
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
�L BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS}
DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IFtRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL PROCESSED
I hereby appty 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicatio a rmit a d work i not to start without a permit on site; that the work will be in accordance
with the a roved lan in the c o 1 ork w c e �r review and a rova/l� lans.���//�
SIGNATURE OF APPLICANT � PRINT NAME� /�i�i�e- 6%�/t C¢LY DATE�2 % I U
APPROVAL INSPECTORS SIGNAT E
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977