P - 48615Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE 7 Z� � 2-- YOUR E-MAIL ADDRESS �W u'�{- 7 ��E
SITEADDRESS l%�`%. � ✓�'�' ���
THIS APPLICANT IS: ❑ OWNER .�9CONTR ACTOR
PROPERTY NAME:
OWNER/ ADDRESS:
TENANT
PHONE:
CONTRACTOR NAME: �.� V`� �
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #�
LICENSE, BOND AND STATE BOND #�
CERTIFICATE OF ADDRESS: �� 7 U 1
INSURANCE pHONE / (� 7 � S-
PERMIT TYPE ��GLE FANt7LY
TYPE OF WORK: I� NEw
DETAILED DESCRIPTION OF WORK
��
G I�
�
l� d o �`a
❑ TWO FAMILY
�,�REPLACEMEN?
t G'�l L� ��
CITY
CITY I
FAX
Permit No.�
Received By:
Date Rec'd:�
0 lM �6� ��"� �
3TATE ZIP
_ EXP DATE
EXP DATE
�v �'� STATE � ZIP ] , J �
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (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 SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LALTNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER � OTHER
Niuriber of fixtures �d�, �35.dfl x $35.U0'� $
�tate Surchazge � �. ' �.�1Q ;
,
��. . ,. .
(�49I�TNIU'VI �4a.ti�j . Tatal S� �°�""�� " �
�
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 ordinance and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applica io for permi and work is not to start without a permit on site; that the work will be in accordance
with the approved plan i th c 11 h requires review and approval of plans.
SIGNATURE OF APPLICANT ��' PRINT NAME DATE
APPROVAL INSPECTORS SIG T /L _ DATE_ �- ,.�1 ^'
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
�i �