P - 44979Building PLUMBING
Inspections RESIDENiIAI., APPLICA�'ION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE�-,-zo>>
DATE ;� (�Ir1
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTI' A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERNIIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
iM � �� l� JE
❑ OWNER J�ONTRACTOR
ADDRESS: I � 11
PHONE:��
NAME: �,fV�'
STATE LICENSE #_
STATE BOND #
ADDRESS:�
PHONE �� J_ .
�SINGLE FAMILY
/�-
❑ NEW
DETAILED DESCRIPTION OF WORK
CITY
❑ TWO FAMILY
�REPLACEMENT
� TOWNHOUSE
Permit No.:
Received By:
EXP DATE
EXP DATE
' STATE ZIP �2
T_ _ _ .
FEES ARE BASED ON $10.00 PER FIXTURB, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi�. NIINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFfNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET 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 permit a1 d wor ' not to start without a permit on site; that the work will be in accordance
with the approved plan in th se o all h� h ire review and approv�/� plans. �
SIGNATURE OF APPLICANT �� � ;�E /`�l�K GGrF//�-�ij/ DATE , J�� ' l
APPROVAL INSPECTORS SIGNATURE _ , � DATE
U City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977