P - 44858Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECT7VE 1-1-2011
DATE
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
�OWNER/
� TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
YOUK E-MAIL ADDRESS
❑ OWNER OCONTRACTOR
ADDRESS: �;� �� �,V@�'�Q 91I l�I� CITY,
PHONE: �%I�.'3" y39 ' g �.S g
Permit No.:
Received By:
Date Rec'd:
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS: CITY
PHONE FAX
�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
�
1� REPLACEMENT
STAT9ILN ZIP .
TE ZIP.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MIN[MUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTTIER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER MET'ER OTHER
THIS IS AN APPLICATION FOR A PERMIT-N07' 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 ordinan and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an ap ica ion for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in e ca e 1lbvorJ�hich requires review and appr al of plans�. P
SIGNATURE OF APPLICANT �•� �/ PRINT NAME���/9ij �,S (;a�t1G� DATE��a '��/
APPROVALINSPECTORS TURE -�— naTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977