P - 48638Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE_y�� �/ �
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
O OWNER
NAME:���
ADDRESS:
PHONE: j"j���
NAME:
STATE LICENSE # I
STATE BOND #^�
ADDRESS:
PHONE
SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
YOUR E-�Iv1AILl�D�J2ESS
Permit No.'���
Received By:
Date Rec'd: .1�
CITY
EXP DATE
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❑ TWO FAMILYAEA I w9 T��13USE
i�7L�f"'�
REPLACEMENT
0
STATE
ATE ZIP.
FEES ARE BASED ON $10.00 PER F[XTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/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)
_ 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 plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application a pe ' and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th �case of�ll o c � ich re s review and appr val of pl ns.
SIGNATURE OF APPLICAN �" PRINT NAME� DATE �� I�
APPROVALINSPECTORSSI TURE
__
j City of Fridley
Building Inspections Department ,
6431 University Avenue NE, Fridley, I�4N 55432
763-572-3604
FAX: 763-502-4977
0