P - 48096Building PLUMBING
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-5�2-4977 FAX EFFECTIVE 1-1-2011
SITE ADDRESS _J
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
❑
ADDRESS:
PHONE:
CONTRACTOR N,�; KdV{�1• (�t -�
SUBMIT A COPY OF STATE LICENSE #
YOUR STATE
LICENSE, BOND AND STATE BOND n#
CERTIFICATE OF ADDRESS: `�
INSURANCE pHONE
PERMIT TYPE' SINGLE FAMILY
�rYrE oF woxx: ❑ NEw
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
CITY
FAX
1
❑ TWO FAMILY ❑ TOWNHOUSE
C�REPLACEMENT
, .,
Permit No�
Received By:F ' �'U' �
� �����
EXP DATE
EXP DATE
STATE��ZIP �L
��tX�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMCJM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTf�S WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ O'CHER
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 and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th e all}'�� ' requires review and appro al of pl —
SIGNATURE OF APPLICANT �' �' PRINT NAME��� IC._ �� DATE
APPROVAL INSPECTORS SIGNATURE J/\ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977