P - 48172Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE � "' /
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
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❑ OWNER BCONTRACTOR
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Permit No.:
Received By:
Date Rec'd: 1 1 �
f�Cx L.2 � STATE�P L% 2 J
corrrx�c�roR NAME: �-2-� -�ra�• c 1,�•� �� �.,�.. Bl��
SUBMIT A COPY OF STATE LICENSE #�� 'Z 6, EXP DATE
YOURSTATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ,�DRESS: /�/ 2 Gl � I' q� S%�� CITY �� STATE ZIP
INSURANCE
PHONE FAX
PERMIT TYPE �� SINGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRII'TION OF WORK
❑ TWO FAMILY
¢I�AEPLACEMENT
❑ TOWNHOUSE
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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/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CI1'Y LIC) SWA�IlvIING POOL WATER SOFTNER ($35)
CLOTI-tES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (E15)
_ DISHWASHER _ LAUNDRY TR.AY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTI�R
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 i ot to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all work which re uir s eview and approval of plans. `
SIGNATURE OF APPLICANT '� RINT NAME DATE !" 7�
APPROVAL INSPECTORS SIGNATi�� . �� DATE , �7
" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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