Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 06/14/2018
Permit No.:____________
Received By:__________
Date Rec’d:____________
DATE_____________________________________________ YOUR E-MAIL ADDRESS _____________________________________________________________
SITE ADDRESS __________________________________________________________________________________________________________________________
THIS APPLICANT IS: OWNER CONTRACTOR
NAME:______________________________________________________________________________________________________
ADDRESS:___________________________________________CITY____________________________STATE_____ZIP________
PHONE:_____________________________________________
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
NAME:________________________________________________________________________________________________________
STATE LICENSE PC#__________________________________________________ EXP DATE _______________________________
STATE BOND MB# ____________________________________________________ EXP DATE _______________________________
ADDRESS:____________________________________________CITY__________________________STATE_______ZIP__________
PHONE ________________________________________________ FAX __________________________________________________
SINGLE FAMILY TWO FAMILY TOWNHOUSE
DETAILED DESCRIPTION OF WORK ___________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW).
Number of fixtures @ $10.00 ____ x $10.00 = $_________
Number of fixtures @ $15.00 ____ x $15.00 = $_________
Number of fixtures @ $35.00 ____ x $35.00 = $_________
State Surcharge $______1.00
(MINIMUM $35.00 plus surcharge) Total = $_________
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 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 case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT ______________________________________PRINT NAME________________________________DATE______________________
APPROVAL INSPECTORS SIGNATURE _________________________________________________________________________DATE______________________
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR BUILDING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
7071 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
