P - 48642Building
Inspections
763-572-3604
763-502-4977 FAX
SITE ADDRESS J
TE�S APPLICAN7� IS
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER
YOUR
J�
Permit No. ;
Received By1��
����:�2�
PROPERTY NAME:
OWNER/ ,,�DRESS: CITY STATE ZIP
TENANT
CONTRACTOR NAME: �\� S� w��rl t I� I U j'"� �"J� �1( a
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF pDDRESS: I I7`l CITY �, c
LNSURANCE /�
PHONE �l rL� �j I��' 'I Ud Z3 FAX
PERMIT TYPE �SINGLE FAMILY � TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � �W REPLACEMENT
DETAILED DESCRIPTION OF WORK �P n Fi1C2. GII�� L—J`�"�I`
f�}:����y�]
EXP DATE
Tn- STATE V%� ZIP
FEES ARE BASED ON $]0.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV✓). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CIATf�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �ATER HEATER ($35) FOR IRRIGATION
ATER METER � OTf�R ip ,
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 ase ork which requires review and app al of p�s. i n�,
SIGNATURE OF APPLICANT�i� � PRINT NAME��� ' S0� DATEU�►i1- \���CJ' I�
............. �,,...�..,..,....,..�.�_..... ,..
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977