P - 40736Building PLUMBING
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-$OZ-4977 FAX �FF�-TivF i_�_�mi
�A-rE `"t l l�l l
SITE ADDRESS
TffiS APPLICANT IS:
PROPERTY NAN
OWNER/ ADD
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
YOUR E-MAIL ADDRESS
��R�:
■ • �
r�. :��
. �
�
STATE LICINSE # (��j ''fi) U'Y1 � \ '
STATE BOND #
ADD�S: �a.� c � ��-YQ � �.��i�
PHOIVE 7�0 �"`S 7�' � �-� � FAX
PERMIT TYPE + �SINGLE FAMILY
TYPE OF WORK: I � �"�'
DETAILED DESCRIP'TION OF WORK
�
e
�
❑ TWO FAMILY O TOWNHOUSE
�REPLACEMENT
Permit No.
Received By:
Date Rec'd:
���
�rn vn� 1�/ 3 /J a
EXP DATE
>S� a STATFJ� ZIP SS✓'��o�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WE�RE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MIN[MUM FEE
$35.50.
BATH S1NK/I,AV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CTTY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTFIES WASHER KITCIiFdV SIIVK WATER CLOSET �BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ O"THER
Number of fixtures @$10.00 x 510.00 =$
Number of fixtures @ $15.00 x $15.OQ = $
Number of fixtures @ $3�.00 x $35.00 = $
State Surcharge S 5.00
(MINIlVIUM $�40.00) Tota1= S � � O �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LIN'PIL 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 a rk ' not to start without a permit on site; that the work will be in accordance
with the approved plan in the a of all wo wh' r i r iew and appro 1 of plans.
SIGNATURE OF APPLICANT 0.�,,, I. PRINT N r � DATE I
APPROVAL INSPECTORS SIGNAT E DATE
PLEASE NOTE: SEPARA PE TS FOR BUII.D , LECTRICAL AND MECHANICAL WORK
City of Fridiey
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
Q11