P - 45105Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX , EF�'ECTIVE7-i-2010
DATE _f " {�
SITE ADDRESS �%
THIS APPLICANT IS:
PROPERTY
OWNER/
TENAI�iT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CBRTIFICATE OF
INSURAT�lCE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
NAME:,
ADDRESS;
PHONE:
�UR E-MAIL ADDRESS
S�,
�
Permit No
Received By:
Date Rec'd:
t�f "�9 � � �
NAME:_'�"d�"�t�'`�•�r�. ' _�'a--�s-�'��'4—T– ' .n„'n
STATE LICENS6�i �' R�., .-. . . : EXP DATE
STATE BOND # � ��� � s ��� � � EXP DATE
ADDRESS: � C8``'��'�.�'y � �t�'';� ��d.; '�� �"��,CITY
PHONE 9��°��:.�—�•��c� FAX
'�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�[tEPLACEMENT
❑ TOWNHOUSE
�
ATE1/ �VZIP
ATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH S1NK/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)
_ DISNWASHER ! LAUNDRY TRAY �WATER HEATER ($35) � FOR IRRIGATION
WATER METER _ OTNER
TH[S IS AN APPLICAT[ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 hereby apply for a plumbing permit and I acknowledge that the information above is connplete and accurate; that the work wiil be in
conformance with the ordinances and cod s of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applica � r a rm't and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the f r ic r ' es review and approva �1�q,s- /� r� DATE �` n l
SIGNATURE OF APPLiCANT -�� � PRINT NAME C
APPROVAL INSPECTORS SIGNAT E "�`'���-
" City of Fridley
Buildi�g Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977