P - 44988Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE '� ��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFiCATE OF
IIt1St1RANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL �
1 r^- .
❑ OWNER '�CONTRACTOR
NAME: � �WI/C �✓�,
ADDRESS:6�SG JTl Y�,SD`^. I��Y • CITY
PHONE: 7(s .3 � S%/� 9/�{ 3
Permit No.: l�i� �
Received By!! �"
Da�e'F,�d� � �
A'
NAME: � 0.►/�,l�- S�YU S d 1 �
STATE LICE SE #���JSS ( V�� EXP DATE
STATE BOND # EXP DATE
ADDRESS: IO . L r �• N CITY_ �i1 �►� �AJ�-Q� STATE/y /�%_ZIP����
PHONE JJr' 2- yb 9" � 3 � FAX 952- �169'���
I� SINGLE FAMILY
/'
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
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 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 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 permii but only an ap ication for a aermit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in t ase of� � ich requires review and approval of pl s.
SIGNATURE OF APPLICANT * A T* Tn PRINT NAME�j/�'� �(,�,��, � _DATE I' "'`��� D
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977