P - 42756Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � " � � �
SITE ADDRESS ,� � �
THIS APPLiCANT ►S:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
❑ OWNER
YOUR E-MAIL ADDRESS
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PROPERTY NAME ���(P� ;;�.e �lr,� � �� G,�
OWNER/ ADDRESS: .SS� s�_ y S v �J�+�-Q CiTY
TENANT
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CONTRACTOR NpMg: c l �
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF ADDRESS: �� �tJ �,� t�l /w �Y" CITY , G
INSURANCE PHONE _��, 3"_� �� 7/T%p� FAX _Z
PERMIT TYPE NGLE FA�v1[LY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEw �gEPLACEMENT
DETAILED DESCRIPTION
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Permit No.:a6 � �'�ut�(°
Received B�:� Y�4
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STATE ZIP_
"�XP DATE
EXPDATE
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERENOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB L�E'AS PlPING (NEED CITY LIC) SWIMMING POOl, � WATER SOFTN&R ($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 UNT]L 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 r a pe it d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the� of I wo k � h requires review and approval of lans.
SIGNATURE OF APPLICAN7 ` _PRINT NAME �j� Q� ���U'Sb✓L DATE / a- �J �'l�
APPROVAL INSPECTORS SIGNAT �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977