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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � �g '� 0
SITEADDRESS s %t3
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
y��G.-
❑ OWNER �ONTRACTOR
ADDRESS: CITY
PHONE:
Permit No
Received By'
����:�
NAME: �"��N�/L A�y/NOt!!,� P� 6
STATE LICENSE # O G I t�S-� EXP DATE
STATE BOND #
EXP DATE
ATE ZIP
Q10
nDD�ss: / 7/o r9 /.�X�.�r'J�r"R R(,�ciTY t�'�.96�.✓ sTnTE i+�✓ziP �53-/d
rxoi•rE 6 s/ • Ysa •/T6 � Fax G�i •'Y.�a`� • oc�6 �
1f�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�I2EPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMiJM FEE
$35.50.
1 BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
L BATHTCJB GAS PIPING (NEED CITY LIC) SWIIVIMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KTTCHEN SINK � WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IIiRIGATION
_ 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 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 th�s e�fa�i w hich requires review and approval of plans.
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APPROVAL INSPECTORS SIGN� '
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977