P - 37485Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTrvE �-�-zo>>
DATE�SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
❑ OWNER
NAME:i,
ADDRESS:
CONTRACTOR NAME:_ r�
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #_
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF pDDRESS:�
INSURANCE
PHONE �
PERMIT TYPE INGLE FAMILY
TYPE OF WORK: � NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
❑ TWO FAMILY
�REPLACEMENT
Permit No
Rece���;
Date Rec'd:
_CITY� I� _STA
EXP DATE
EXP DATE
_CITY � STAT
FAX 3�- 2`�
❑ TOWNHOUSE
f°t� i
J
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATHSINK/LAV _FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY ZWATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowl dge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and des of the ty of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a rmit d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the cas� Il"��rGrk i� i• uires review and approv ;o ans�-� (7 �,
SIGNATURE OF APPLICANT �"/ �� PRINT NAME � '� DATE �3
APPROVAL INSPECTORS SIGNATiJRE ' , DATE � ,�
�-�' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977