P - 36752Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE I-1-2011
DATE �=
SITE ADDRESS _
THIS APPLICANT [S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
_ YOUR E-MAIL ADDRESS
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❑ OWNER � $C
NAME: � e
ADDRESS:
PHONE:
NAME: S . � CG
STATE LICENSE #�
STATE BOND #
ADDRESS: �
PHONE ��� I "� L�<
$SINGLE FAMILY
O NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�B'REPLACEMENT
�
CITY
Permit No.:
Received By:�
Date Rec'd: l
ATE ZIP
� EXP DATE f%
EXP DATE
=CITY� L/�i��' -STA�
FAX �� �
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❑ TOWNHOUSE
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FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
� BATH SINK/LAV FLOOR DRAINS � SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT 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 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 an work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the cas w whic quires review and approv�a f pla s. '/
SIGNATURE OF APPLICANT PRINT NAME ,,_ j C�0 �\ D C.� �^^ DATE � � I
APPROVALINSPECTORSSIGNA F. A - r�n�rr �. .. . .
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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