P - 84774Building PLUMBING Permit No.: �
Inspections RESIDENTIAL APPLICATION Received B�
763-572-3604 CITY OF FRIDLEY D���'�:�� Q1�
763-502-4977 FAX EFFECTIVE I-]-2012
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DATE�SITE ADDRES _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
DETAILED DESCR]
� /YOUR E-MAIL ADDRESS
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❑ OWNER /�CONTRACTOR
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NAME:
ADDRESS:
PHONE:
NAME• >�j.7l:SFJ _f�r ��
STATE LICENSE # r � �L1 �{ � C� ��
STATE BOND � `% �'J (`��� 7-�y �/ _
PHONE �
�INGLE FAMILY
❑ NEW
'ION F WORK
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O TWO FAMILY
�EPLACEMENT
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CITY STATE ZIP
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EXP DATE � �
EXP DATE `� 3
_C[TY S`72CC �/ STATE,�,[LZI
_ FAX
❑ TOWNHOUSE
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BEI,OW).
BATH SINK/LAV FLOOR DRA[NS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LfC} SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
�WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L PROCESSED
I hereby apply for a plumbing permit and I ackno dge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes t ity of Fridley and with the Minnesota Construction Codes; that I understand this is
not a perrr►it but only an applicatio r nd work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the cas of i requires review and approvalp�l�ns6�7 /� DATE l0 /
SIGNATURE OF APPLICANT PRINT NAME � � L.7e-�
APPROVAL IIVSPECTORS SIGNA _ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977