P - 60362Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX r_rrrn�rrvr_ i i �ni�
DATE rY ' /al ^
SITE ADDRESS ���
TfiIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
YOUR E-MAIL ADDRESS
_ , .---..
■• /►! :
Permit No.:��a"C�
,
Received By: �
Date
NAME:
ADDRESS: CITY STATE ZIP
STATE LICENSE �!_
STATE BOND # _
ADDRESS: !� l7
PHONE _� j��- i
SINGLE FAMiLY
TYPE OF WORK: I � ��'''
DETAILED DESCRIPTION OF
�-.._ _ .., �.�-- _�..
0
❑ TWO FAMILY
❑ REPLACEMEN7'
EXP DATE
�_ EXP DATE
CY��� mfi�i�i-�1STATF, /" ZI � � i
F,�,� � �/- 6 � • Ta� 5
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELQW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS �CSHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWA�4vIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTf�R
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 al r h requires review and appj al of plans.
SIGNANRE OF APPLICA , - i�� a PRINT NAME`��3�r /d"�L DATE y'�/a2 /.2
APPROVAL IlVSPECT IGNATURE �-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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