P - 48196. . � .
Building p�[,�J����E�
Inspections ���������, �p��,���'�'���
763-572-3604 ���� �� �,�����
763-502-4977 FAX EFFECTIVE7-1-2010
DA`r� r- �l-\
SI1'E ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFTCATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
ADDRESS
�ti ✓\V� �`�
❑ OWNER �CONTRACTOR
r
Permit No.: L �%
Received By:
�.-.-,.� .
AT�l�ZIP
STATE LICENSE #�E/) ���0 �'�i � EXP DATE ��_�Zi
STATE BOND # EXP DATE
ADDRESS: CITY o� STATE��IP SSIZ,3
PHONE �`�J�� � �'J' I �7�it7 F��'
�7 SINGLE FAMILY
f� ►i� I
DETAILED DESCRIPTION OF WORK
❑ TWO FAMII.Y ❑ TOWNHOUSE
�REPLACEMENT
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT R�RE NOTED. FIXTURES: (INDICATE TOTAL NiJMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SII�KQ.AV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CTTY LIC) SW1IvIIvIIIQG POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK T WATER CLOSET BACKFLOW PREV. (S 15)
DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbing permit a acknow ge that the information above is complete and accurate; that the work will be in
conformance with ihe ordinances an codes the of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application or a pe a work ' not to start without a permit on site; that the work will be in accordance
with the a roved lan in the case o h' d ro al of lans./1. t,_� s•,�
SIGNATURE OF APPLICANT ��� •. i NAME ��� S C9 �/`�llATE�_� "� RL
:� PLEASE NOTE
C�// Ci4y of Fridley
�ui�ding Inspections Depart�ient
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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