P - 45822Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �f �
SITE ADDRESS L
THIS APPLICANT IS:
PROPERTY NAME:
OWNER/ aDD�s
TENANT
PHONE:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
-f � � P�Iv„�(" iv�
❑ OWNER
CONTRACTOR NAME:�
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #,
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF ADDRESS: ��I
INSURANCE pHONE 'I� � "
PERMIT TYPE
TYPE OF WORK: I� NEw
'' y
; _ �'cl J,
FAMILY ❑ TWO FAMTLY
DETAILED DESCRIPTION OF WORK
�PLACEMENT
CITY
CITY_
FAX
❑ TOWNHOUSE
Permit No.f.°l
Received By:
I���ec�
RC
TAT�/U ZIPJ��4 �L
EXP DATE
EXP DATE
� STATE�ZIP � s''-
—._, „_ i
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 SOFTNER ($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 ardinances and codes of th City of �idley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit a wo�'c is not to start without a permit on site; that the work will be in accordance
with the approved plan in the of 1 wo 'ch ir�s review and approvalrof pl �
AP ROVAL INSPECTORS SIGNATiJRE �,. `�, P�N/�N� ME� / 1�� �"/II��/ DATE �.v� l
.�- DATE
' Ci �� of Fridley
Bui ing In;�pections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977