P - 39374Building
PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECr,vE i-,-ZOi i
DATE �j cJ ` �" � C� YOUR E-MAlL ADDAESS _ � �, ,F-,
SITE ADDRESS __�� C� (.C%47 �j l.� .' n `Z �i'�l � �" �i !.� /- r; cL� CVt 1
THIS APPLICANT iS:
PROPERTY
OWNER/
TENAIYT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER �ONTRACTOR
PHONE:
Permit No.:
�
Received By:�
Date����: � �- � � � �
STATF�I%'i Z1P
STATE LICENSE# (�(p j'�, �1 v L� -' �1� EXP DATE I Z'-' 3/— Z,�` 1 7
STATE BOND # 7� CX� �'�O L/� � Zi EXP DATE ��� ,� /' Z p/�
ADDRESS: �(i � I�i� . Lt 5� �► CITY_�,,/�! : v� _S STATE�ZIP_1Z���
PHONE �Z � Z" yK ����'l 3 U FAX
�$SINGLE FAMfLY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
[� REPLACEMENT
DETA LED DESCR[PTION OF WORK I�e�O% (,� �,c9�, ��'lc�, ,t�e,,� �}- h� � 2
Lc ;�G� �' �h K'S w-��, GL •`�S G, w�r � h.o,. S
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.SQ
BATH SINK/LAV FLOOR DRAINS SHOWER
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER :� KITCHEN SINK WATER CLOSET
� DISHWASHER _ LAUNDRi' TRAY �WATER HEATER ($35)
_ WATER METER
TH[S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
WATER SOFTN6R ($35)
� BACKFLOW PREV. ($ I S)
FOR IRRIGATION
_ OTHER
I hereby apply for a plumbing permit and I acknowledge that the information above is comp(ete 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 the,� of a ch requires review and appro al of plans.
SIGNANRE OF APPLICANT __ ���,_.- �'�� PRINT NAME_ �ji�..�� �7,•c� %Z. DATE G/ "`. � .�-d //
APPROVAL INSPECTORS SI A� T� __ ___ ___ _ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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