P - 84275Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I �
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
Permit No. ��"� �a` � � �� �'
Re K���� B�• - �
Date ec'd:
NAME:
ADDRESS: CITY STATE ZIP
STATE LICENSE #
STATE BOND #
ADDRESS: /v� ,��6 /��C�/crfl�'> i% i`" U". C:I CYG,
PHONE /7 �`! �9 FAX
PERMIT TYPE °"""`
TYPE OF WORK: � NEW
DETyAILED DESCRI T�ON OF
%�s ?!X G t��°�� %I�'�.
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
%�,REPLACEMENT
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EXPDATE
�XP DA E
.,, � STAT$�_ZI � C�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW).
2 BATH SINK/LAV FLOOR DRAINS � SHOWER WATER PIPING
/' BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
/ CLOTHES WASHER � KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($IS)
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 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 of all work whic r ires review and approval of plans.
,%� �/ , j
SIGNATURE OF APPLICANT PRINT NAME /✓li� 1"O � ee DATF�Q � 6��/ �
APPROVAL INSPECTORS SIGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
DA'