P - 45008Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-36,04 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-i-2010
DATE , _ YOUR E-MAIL ADDRESS __
SITE ADDRESS �� C��--I ,�
THIS APPLICANT IS: ❑ OWNER
PROPERTY NAME: l�'
OWNER/ � `
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TENANT A�DRESS:� �
P�oN�: �..Q � a
CONTRACTOR NAME:
SUBMIT A CQPY OF
YOUR STATE STATE LICENSE #�
LICENSE, BOND AND STATE BOND # C� �
CERTIFICATE OF ADDRESS:�� �
INSURANCE pHONE�.�`J �
PERMIT TYPE � '��NG�E Fa1�ttLY
TYPE OF WORK: � NEW
DETAILED DESCRIPTION OF WORK
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❑ TWO FAMILY
Permit No.: G
Receiyed By:
Q�r���n r��
datte"�.'�ec "�9.
CITY STAT�ZIP��
� ��'� �� � � a ����n�e.f�
' EXP DATE � �
EXP DATE � �.
� CITY S ATE�11 ZIP�
FAjX � � D
❑ TOW'NHOUSE
"� REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES; (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPLNG
� BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
D[SHWASHER _ LAUNDRlY TRAY �WATER HEaTER ($35) FOR IRRIGATION
_ WATER ME?CER _ OTHER
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THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and 1 acknowledge that the information above is complete and accurate; that the work will be i
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this i
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 accordanc
with the approved plan in t of al ork ic equires view and app oval of p ns. '
SIGNATURE OF APPLICANT �I� � �/ PRINT NAME � �� r � il ��_DATE �� � � �
APPROVAL INSPEC'i'ORS SIG AT „ r-z_
�-�' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977 '
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