P - 42254Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE �-i-aoio
DATE �1 'l �i� �r � YOUR E-MAIL ADDRESS
srrE a���,ss t Y � � G� � '�% � �; �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER [�CONTRACTOR
ADDRESS: �y �' S rv L'r-�' �""�� `� � CITY
PHONE: la / � .. .� l� �' � �•1 o y —
NAME: Terry Overacker Plumbing, Inc.
STATE LICENSE # 502 E Main Street
STATE BOND # Anoka, MN 55303
License# 061945PM
ADDRESS: 763-572-8880
PHONE
❑ SINGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�SREPLACEMENT
DETAILED DESCRIPTION OF WORK ✓�c-C��-
Permit No.: :�'r�Z=``�=' �
Received By:�a ���
D�e�c�U 1
ATE Y�'`' ZIP r� Y32
' DATE
'DATE
STATE ZIP,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER
BATHTUB GAS PIPING (NEED CTfY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SINK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35)
WATER METER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
WATER PIPING
� WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR IRRIGATION
OTI�R
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 pernut but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case f all work which requires review and approval of plans. /
SIGNATURE OF APPLICANT �� s� � ui..LZ PRINT NAME�l� L j� i�_ /C l� �' ��c�- DATE ��� �d
APPROVAL INSPECTORS SIGNAT
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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