P - 84352Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE �(J � L
SITE ADDRESS J
THIS APPLICANT IS
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 �ONTRACTOR
NAME: (��9� �/t�s//�e-r
ADDRESS: ��/'� � CITY
PHONE:
NAME: �JL� r7` �
STATE LICENSE #
STATE BOND #
PHONE _�_[_��
�INGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�tEPLACEMENT
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FAX
❑ TOWNHOUSE
Permit No.:plal�-O I bl t�
Received By:�_
Date Rec'd�
ss ��
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STATE ZIP
_ EXP DATE
_ EXP DATE
�'� � STATE I�NZIP�5s37 °I
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW).
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 it 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 al or ich r uires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME ��� �" DATE / O `�-� ��
APPROVAL INSPECTORS SIGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
DA