P - 45225Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_��/ '" /Z'
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING Permit No.: �`'�I� ���
RESIDENTIAL APPLICATION Received gy:
CITY OF FRIDLEY �at��:�a:���� ��
EFFECTIVE I-1-201I
YOUR E-MAIL ADDRESS � S//JG (� � 7(� �� (�/�
_ ic, � - �
WNER ❑CONTRACTOR
NAME: O � � , I �/'
ADDRESS: ,S-� 3� S � ^
PHONE: �?_ Z ZO- '7 �
NAME:
STATE LICENSE #
STATE BOND �!
ADDRESS:
PHONE _
INGLE FAMILY O TWO FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCR[PTION OF WORK X Y►'L�!+
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CITY
fAX
❑ TOWNHOUSE
'l.�' STATj"{�//(/LIFW� 7
_.-- ��Z - ys y-s� Z
EXP DATE
EXP DATE
_ _STATE ZIP
�Lfi��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM fEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PfPING
_ BATHTUB GAS PfPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (SIS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRR[GATION
_ WATER METER � OTHER
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 wili 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 a ication for a p nd �ork is ,to start without a permit on site; that the work will be in accordance
with the approved plan in t e of all wo w iclirequ�re and approval f �la�1 I�t' /J�'��7�
SIGNATURE OF APPLICANT P INT NAME ��-�/� �N� �I�L��ATE `V �% ���
APPROVAL[NSPECTORSSIG R DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977