P - 35769Building PLUMBING perrnitrlo.:�1,L` �t`�
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE �-�-20>> ��e���
DATE �` � r� YOUR E-MAIL ADDRESS
SITE ADDRESS �C� � ^ O ly -�2.'""'Fp.�l � � �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER �CONTRACTOR
�rw�S i �•' l� t�2.�ln o..
ADDRESS: �� p v �� � � . CITY
PHONE: �IG.3 - ��l" ��6�
'ATE I,�/.�IP S:.S1I��
STATE LICENSE # ScI�3 J EXP DATE I�- ,3 f� l(
STATE BOND t!
ADDRESS:
PHONE
�GLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�.1FEPLACEMENT
EXP DATE
TY STATE ZIP
FAX
❑ TOWNHOUSE
�k', �.��'
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
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER � KITCHEN SINK WATER CLOSET
= DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
_ WATER SOF'INER ($35)
_BACKFLOW PREV. ($15)
FOR IRRIGATION
OTHER
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 ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application 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 the as f all work which requires review and approva of p s. /
SIGNATURE OF APPLICAN'�� �, PRINT NAME/�� �r�',sL DATE �(_ l�
APPROVAL INSPECTORS E � ne�rF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977