P - 41793Building PLUMBING
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE�-i-ZO�o
DATE L�
SITE ADDRESS t
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
YOUR E-MAIL ADDRESS
❑ OWNER 6,�CONTRACTOR
0
ADDRESS:�_aYtil CTI'Y.
PHONE: ��-c- � J � I '_ �
CONTRACTOR N�,:��
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #_
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF p,DDRESS:��
INSURANCE pHONE��
PERMIT TYPE �GLE F�n'Y
TYPE OF WORK: � �'
DETAILED DESCRIPTION OF WORK
J l0"�lto
❑ TWO FAMILY
�EPLACEMENT
FAX
❑ TOWNHOUSE
Permit No.;
Received By:
Date Rec'd:
�STA'1
EXP DATE _�,._
EXP DATE
Li� STA17
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER P1PING
BATHTUB GAS PIl'ING (NEED CITY LIC) SWIMNIING POOL WATER SOFTNER ($35)
CLOTI-�S WASHER = KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTI�R
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 and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all work wh" re re� w and a}�roval of plans.
SIGNATURE OF APPLICANT �,�1 '��'j'�_� fl\y� w DATE ���Cj'"I I
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604
FAX: 763-502-4977
�U o�Z2
�