P - 46599Building PLIJMBING Permit No.: ��o o`�
Inspections RESIDENTIAL APPLICATI4N x ������"�
763-572-3604 CITY OF FRIDLEY ����� a.
763-502-4977 FAX ��,n.,,� , , �,,,
SITE ADDRESS _
THIS APPLICAIVT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
Y�UR STATE
LICENSE, BOND AND
CER'I�ICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
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PHONE -/(D �
�SINGLE FAMII.Y
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❑ TWO Ft1MQ.Y
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EXP DATE i �
EXF DATE
CITY d �
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O TOWNHOUSE
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FEES ARE BASED ON SI0.00 PFdt FIXTURE, EXCEPf WHE[tE NO'CED_ F[XTURES: (INDICATE TOTAL NUMBER OF fiACH BII.OW}. IuIINiMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS 3HOWER WA'TER PIPING
BATHT[JB GAS PIPING (NEED C1T� LIC) SWIMMING POOL � WATIIt SON�7dF�t (�35)
CLOTHES WASFIIIt R:TfCI�N SINK WATE�t CLOSET BACKFLOW PREV. (E15)
_ DISHWASHIIt _ LAUNDRY TRAY WATER iiEATER (S35) FOR IRRiGATION
� WATER METER O'I�IER
'FHIS IS AN APPLICATION FOR A PIIiIvIlT-NOT VALID UNIiL PROCESSED
I hereby apply for a plumbing permit and I aelcnowledge that the infonnation above is compl�e and a�w�ate; dsnt the w�k will be in
conformance with the ordinances an of the City of Fridley and with the Minnesotit Cans�ction Codes; that I uacierstand tlus is
not a permit but only an applicati n for ' and woiic is not to start withaut a permit on site; that the work will be in accordance
with the approv� plan in the f all w review and appro of plans f c
SIGNATfJRE OF APPLICANT NAME ��j �!/� Lk� � DATE �
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: '763-502-4977