P - 45001Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
Permit No.: � 6�0 �
Received By: /�
Date Rec'd:��
DATE I���� �V YOUR E-MAIL ADDRESS �-�� C�-�-1!'� ��i � C c'�`a�
SITE ADDRESS l� � t� � ti,(.N'i �� �/�/�
THIS APPLICANT IS: �bWNER ❑CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
��
�
NAME: � �'�t,��P -�' ✓ =t ls � �� �-� �s al
ADDRESS:�D���L✓(�_��% �� CITY �i 1 ULC-' / STATE'��ZIP:?y�� �
PHONE: �(v � " �7 � !>O � �S
NAME:
STATE LICENSE #
STATE $OND �
EXP DATE
EXP DATE
ADDRESS: CITY STATE ZIP.
PHONE
�INGLE FAMILY
TYPE OF WORK: � �W
DETAILED DESCRIPTION OF WORK
-�., /.1/i,/ � tit.,t,-� uJ/,�' .9il.D
FAX
❑ TWO FAMILY ❑ TOWNHOUSE
0 REPLACEMENT
� .6� WC�..�„� .' �t�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED,
$35.50.
BATH SINK/LAV R DRAINS
BATHTUB i����A�S PIPING (NEED CITY LIC;
� CIATHES WASHER KITCHEN SINK
_ DISHWASHER � LAUNDRY TRAY
FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
_ SHOWER
_ S WIMMING POOL
WATER CLOSET
_WATER HEATER (S35)
_ WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
X WATER PIPING
�WATER SOF7NER ($35)
BACKFLOW PREV. ($15}
FOR IRRIGATION
_ OTHER
I hereby apply for a plumbing permit and I aclrnowledge 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 anc3 work is not to start without a permit on �rte; at fte w.pr � Il be in accordance
with the approved plan in the c f a which requires view a d approv plans.0 �� �•�
SIGNATURE OF APPLICANT � � PRP:r-- AME . I. �
APPROVAL INSPECTORS SI(' .� RE ./ �� � %' _ �!
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977