P - 37483Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DnTE K i I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
r��'� l•°l�' �` �
❑ OWNER �CONTRACTOR
NAME: ��'�f% � ��
ADD�sS ,��3 M�os��u'Ye G��e 17r ��TY�
PHONE: �V�7 �' � �'G �! ��,�
NAME: 4�/Y' �� Pr f •�11
STATE LICENSE # �
STATE BOND #
ADDRESS: "i� /YLG�!��I I ,�� T �� CITY�
PHONE 11,t %� � /�I"v� FAX
�$INGLE FAMILY
7`�
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
❑ TOWNHOUSE
Permit No.
Received By:
Date �`C�d`
i
EXP DATE
EXP DATE
STAT� ZIP J� �L
�l , 2� �i l, �I./�f1X
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET 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 pIumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ardinances and codes of the City of Fridley and with the Minnesota Consiruction Codes; that I understand this is
not a permit but only an application fo e i and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the cas all o� i h equires review and approva of lansy��� p /
SIGNATURE OF APPLICANT PRINT NAME ���-- C�l�(iS ''� DATE 0 I�1 I'
APPROVAL INSPECTORS SIGNATURE . __ _ DATE _ f�____
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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