P - 36787Building PLUMBING Permit No.:�..0 �
Inspections RESIDENTIAL APPLICATION Received B:
763-572-3604 CITY OF FRIDLEY Da�� � �� �
763-502-4977 FAX _ EFFEC�nvE �-�-zo� � �.
DATE 15 ' /e�[ �
SITE ADDRESS '
THIS APPLICANT [S
PROPERTY
OWNER/
TENANT
PHONE:
a�-v�'
O OWNER
CONTRACTOR �
NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF ADDRESS:�
[NSURANCE pHONE � / }
PERMIT TYPE I �'SINGLE FAMILY
TYPE OF WORK: � � NEW
DETAILED DESCRIPTION OF
YOUR E-MAIL ADDRESS
�
❑ TWO FAMILY
�jREPLACEMENT
CITY
FAX
0 TOWNHOUSE
.
r
A
r
EXP DATE �R;1 �� 1— e�. D I e7+
EXP DATE ��Z �c'3 I '� �, _� �
1[� STATEj��ZIPS 7
FEES ARE BASED ON St0.00 PER FiXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
1 BATH S(NK/I.AV FLOOR DRAINS SHOWER WATER PIPING
� BATHT�1g _ GAS PTPING (NEED CfTY LIC) SWIMMING POOL WATER SOFTNER (E35)
_ CLOTHES WASHER _ KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR tRRiGATION
_ WATER METER OTHER
TH[S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and 1 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 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� of�a�J w ires review and a val of pl Q `^
SIGNATURE OF APPUCAN�1, � G!� :��� �. PRINT NAME� �__��Z. DATE O' o'�� I�
APPROVAL INSPF.CTnRS St�nu+(�itRF '—G� _ . __
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977