P - 39627Building PLUMBING
Inspections RESIDENTIAL APPLICATION
�63-s�2-3�04 CITY OF FRIDLEY
763-502-4977 FAX sFFECr,ve �.�-2oi i
DATE�
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
L[CENSE, BOND AND
CERTIFICATE OF
[NSURANCE
PERMIT TYPE
TYPE OF WORK:
DETAILED DESCRI
YOUR E-MAIL ADDRESS
'.�'OWNER OCONTRACTOR
NAME:_['l�Y i.t 11i1 ir��tQ S
ADDR6SS:�CS�{ l�t1C�C+C�v LCA;�tp N- CITY '�1}
PHONE: T� �j -- SO'L, - � i'�-',j
Permit No��(l` 4
Received By:
Date Rec'd:r- /
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS: C1TY
PHONE FAX
�'SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
❑ NEW
OF WORK
�REPLACEMENT
TATE�N Zl P� 2,
STATE ZIP.
��
FEES ARE BASED ON $10.00 PER F[XTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMB�R OF EACH $ELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRA(NS SHOWER � WATER PIPING
� BATHTUB _ GAS PIPING {NEED CITY L1C) SWIMMING POOL WATER SOFTNER ($3S)
_ CLOTHES WASHER _ KITCHEN SINK ' WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRlGAT10N
_ WATER METER OTHER
TH[S fS AN APPLICATION FOR A PERM]T-NOT VALlD UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowleclge that the information above is complete and accurate; that the work will be in
conforntance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that 1 understand this is
not a permit but only an application for a permit n wor is not to start without a permit on site; that the work will be in accordance
with the approved pian in th c se of a�l w which r es review and appro al f plan
SIGNATUREOF APPLICANT ' PRINTNAME �� �_� y�,.,�j L DATE �� ��,��.'?� �
APPR(lVA1.INCPF(`T(1RC CI _lU TnAC _ �. L iw l v _.__.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977