P - 42151Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ,�
SITE ADDRESS G
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
.IE
❑ OWNER �ICONTRACTOR
CrrY
Permit No.: 2�
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CONTRACTOR NAME: CMamplon Rlumbing
SUBMIT A COPY OF STATE LICENSE # # 61770-PM
YOUR STATE EXP DATE
LICENSE, BOND AND STATE BOND # � r EXP DATE
CERTIFICATE OF �DRESS: CITY STATE ZIP
INSURANCE pHONE � FAX
PERMIT TYPE
TYPE OF WORK:
�INGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMII,Y
�REPLACEMENT
s+u,u ec) s � �n
❑ TOWNHOUSE
FEES ARE BASED ON $10.00 PER FIXTCTRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUM FEE
$35.50.
BATH SINKJLAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTLTB GAS PIPING (NEED CTI'Y LIC) � SWIMMING POOL WATER SOFTNER ($35)
CLOTF�S WASHER = KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
i DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
T$IS 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 far a rt�i�"at d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c Se ° or ic es review and approval of plans.
SIGNATURE OF APPLICANT ��� NAME JC,l�VV1�E'ts '- .. `�,�,�DATE_��°'_�,I' I�
APPROVAL INSPECTORS SIG , �I i ��I i
- City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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