P - 48197Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX „rrr,.TT,,,. , , ��„
DATEC/ -� '
SI1'E ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
0
YOUR E-MAIL ADDRESS 4'
'r�l/ Q �.z./ "� A � l . `.
Permit No:�� �" UIX� JJ
Received By:
Da�'d:� � � �. L � �
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CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF pDDRESS: CITY STATE ZIP
INSURANCE
PHONE FAX
PERMIT TYPE I ��GT.E FAMILY
TYPE OF WORK: I � �"�'
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�EPLACEMENT
❑ TOWNIiOUSE
FEES ARE BASED ON $10.00 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 SOFINER ($35)
CLOTI-IES 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 UNTTL 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 c e of all o which reyuires review and appro,v/�1 of 1 /
SIGNANRE OF APPLICAT��i�vLJi���'%l� PRINT NAA�,JU ��� � �GG�"�'y DATE -- U" _
APPROVAL INSPECTORS SIGN��r � ' DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977