P - 42752Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I ���� � �
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY NAME:�
OWNER/ ADD�s
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER
YOUR E-MAIL ADDRESS
Permit No.: ?iQ�� � ��
Received By:
t4�"��e�'�:� 0 3 � 01
CONTRACTOR NAME: Champion Plumbing
SUBMIT A COPY OF STATE LICENSE # # 61770,PM EXP DATE
Youx sTATE 651-365-1340
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: � ' CITY STATE ZIP
INSURANCE pHONE ' FAX
PERMIT TYPE
TYPE OF WORK:
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
Q�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). NIINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER HITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR Il2RIGATION
_ WATER METER _ O'TI�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 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 at�work, �ch,� ��i� eview and appr Qval of plans. .. �,n �/ p,/r�
SIGNATURE OF APPLICANT � �"�" `� �� ����� NAME.JCvYTI� �� ��.IlcJ9 DATE� �'�C% l `--'
APPROVAL INSPECTORS SIGNATURE - i�. Z�—
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: ?63-502-4977
I I c� -�