P - 45316A
.
Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX �FFECTZVE�-i-zoio _ __
DATE � " I `
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
Z�g
❑ OWNER
�
YOUR E-MAII, ADDRESS
� • � i�
L9�ONTRACTOR
CITY
--c��l 7
Permit No.:
Received By;,
Date Rec'c�
ATF�ZIP ���i Z
NAME: Champ(an F�lumbin
STATE LICENSE �t � ��M EXP DATE
STATE BOND # EXP DATE
ADDRESS: Farvan� i1A �.gs� CITY STATE ZIP
PHONE . _ F�
PERMIT TYPE I �SINGLE FAMILY
TYPE OF WORK: I � �W
❑ TWO FAMILY ❑ TOWNHOUSE
�-REPLACEMENT
DETAILED DESCRIPTION OF WORK � �-��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT �VFIERE NOTED. FIXTCIRES: (INDICATE TOTAL NUNIBER 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 HITCHEN SINK WATER CLOSET _BACKFLOW PREV. ($15)
DISH WASHER i LAi7NDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
^ WATER METER _ OTHER
(MINIMUM $40 00) Tota1= $ i.�r} r�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work wiIi be in
conformance with the ordinances and codes of the City of Pridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and rork is not to s rt without a permit on site; that the work will be in accordance
with the approved plan in the case of ic ��tAap ro f plans. f
SIGNATURE OF APPLICANT DATE �` (� 1
APPROVAL INSPECTORS SIGNA
� PLEASE NOTE: SEPARA PE T' ` ILDING; ELECTRICAL AND MEC ` I RK :'
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
� �3�5Z
�