P - 42242Building
Inspections
763-572-3604
763-502-4977 FAX
DATE lli`IX r
SITE ADDRESS �
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE I-I-2010
❑ OWNER
YOUR E-MAIL ADDRESS
PROPERTY NAME: �� � u ��
oW�� ADD�s: � a � ��T�
TENANT ,
PHONE:
Permit No.:
Received By•
�
Date �id:
A
SUBMIT A COPY OF ST�,� L,� ance onnections Inc � , EXP DATE
YOURSTATE
LICENSE, BOND AND sT�,� Bor�D � 1313 D� n ita �;� EXP DATE �,_
CERTIFICATE OF ADDRESS: CITY STA�TE ZIP
INSURANCE pHONE FAX
PERMIT TYPE
TYPE OF WORI�: I� N�
Y ❑ TWO FAMILY ❑ TOWNHOi1SE
� REPLACEMENT
� � � � • • • ° 1I./,��/�►1/ -r�. -I /I
FEES ARE BASED ON 510.00 PER FIXTURE, EXC�P7' WHP3tE NOTED. FIX'IVRES: �1NDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
S35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPtNG
_ BATHTUB GAS PlPtNG (NEED CITY UC) SWIMMING POOL � WATER SOFTNER (S35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (S15)
_ DISHWASHER _,,, LAUNDRY TRAY , WATER HEA'PER (535) FOR tRRlGATIQN
_ WATER METER _ 011iER
THIS IS AN APPLICATI�ON FOR A PERMIT-NOT VALID UNTIL P1�OCESSED
I hereby apply for a plumbing permit and I acknowledg� that the information above is comp�lete and accurate; that the wock wi1{ 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 th,e work wi�l be in accordance
with the approved plan in the se of all work which requires review and approval of plans.
SIGNATURE OF APPUCANT 1�' PRINT NAME + �.� DATE lY � I°' 1 v
i
. City of Fridley
� - Building Ins�ections Department ,
6431 University Avenue NE, Fridlep, MN 55432
- 763-572-3604
FAX: 763-502-4977
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