P - 44933Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE � � o� Z� G �
SITE ADDRESS S/ O ��C�- �
THIS APPLICANT IS: ❑ OWNER
PROPERTY
OWNERi
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
ADDRESS:
STATE LICENSE #
YOUR E-MAIL ADDRE
'-� l.�( c1 d`i t�l (-- ;
L�ONTRACTOR
C7
Permit No��% � � �-�'� `� �
Received By: �� �
!����1R��Y
EXP DATE
A
2
STATE BOND # EXP DATE
ADDRESS: � S CITY ��f STATE� ZIPSSO't �i
PHONE I� ZE� � Z�I �`� Z�S�, FAX
O�INGLE FAMILY
r�
�NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY � TOWNHOUSE
❑ REPLACEMENT
FEES ARE BASED ON $ t0.00 PER FIXTURE, EXCEPT WHERE NOTED. FlXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MiNIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
$ATHTUB GAS PIPiNG (NEED CITY L!C) SWIMMING POOL WA7ER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET 3 BACKFLOW PREV. ($15)
_ DISHWASHER ` LAUNDRY TR.AY WATER HEATER ($35) FOR (RRIGATION
WATER METER OTHER
7'HIS IS AN APPLICA'fION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pennit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applic � permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th c 1 ork which uires review and app 1 of�P �I s. +
SIGNATURE OF APPLICANT PRINT NAME �n.<x- DATE S" LC% "Z� �/ \
APPROVALINSPECTORSSIGNA E DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977