P - 48163Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �T
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
5UBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTTFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
o- U . �'a.•ni cv
/�-i
Permit No.
Received By:
Tl..�e De..�.7.�
�1
�t�zrn SS y � z_
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS: CITY STATE ZIP:
PHONE FAX
❑ SINGLE FAMILY
TYPE OF WORK: I � ��'�'
DETAILED DESCRIl'TI�N OF WORK
i �. . . �.,9,- . % . ..1 . ..o �
❑ TWO FAMILY ❑ TOWNHOUSE
REPLACEMENT
�
�n �. IQ�n;eG � SG't
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
�$ 5.50.
BATH SINK/LAV _FLOOR DRAINS � SHOWER � WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIlvIIvIING POOL WATER SOFTNER ($35)
CLOTf�S WASHER CHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
� DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IItRIGATION
WATER METER OTf�R
- THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 for rmit work ' not to start without a permit on site; that th work will be in accordance
with the approved plan in the of al eyuir review and approval of p sp f,� ���
SIGNATURE OF APPLICANT � PRINT NAME C7 • I[.K-Y DATE ' I '
APPROVAL INSPECTORS SI A URE - __ DATE
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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