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Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFEC�vs t-i-aoii
DATE �� '"`
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
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❑ OWNER �
NAME: �' � �'
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STATE LICENSE
STATE BOND #
ADDRESS:�
PHONE
❑ NEW
FAMILY
E-MAIL ADDRESS
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❑ TWO FAMILY
FAX
❑ TOWNHOUSE
Permit No.:
Received By:
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EXP DATE J,�C " t� I�' ��--
EXP DATE �U C�— 2-. V �� Z
�..�il �l STATE %!�-� ZIP���4
DETAILED DESCRIPTION OF WORK
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/L.AV _FLOOR DRAINS SHOWER WATER PIPING
BATHTCTB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
C ES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
= ISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit a��acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the�ty of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit' d;work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all work �iic� ` quires review and appr v 1 of plans. ��.z, � �`- '..• � Z., ��
SIGNATURE OF APPLICANT ---� PRINT NAME ��'1�1��'�---� �'- � DATE !
APPROVAL INSPECTORS SIGNATURE — . �'"�� DATE _ _ �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
PLEA5E SEND PERMIT
TO HOME �'�Vl�TERI!