P - 44177Building PLUMBING
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 2-19-09
DATE 1
SITE ADDRESS _
THIS APPLICANT fS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
Permit No.:
Received By:
D��'� C � �00
�� YOUR E-MAIL ADDRESS ��� C'_ / L��',(, -'��
.1 74_�, e r� �
❑ OWNER C�CONTRACTOR
NAME: ' C� �,
ADDRESS: CITY �
PHONE: ,
NAME: 1 !� n L,
STA1'E LICENSE # � EXP DATE
STATE BOND # EXP DATE
ADDRESS:�� � I_C5 �n ��'{, �� CITY � lIA��F
PHONE
�SINGLE FAMILY
TYPE OF WORK: I �NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
*REPLACEMENT
FAX
❑ TOWNHOUSE
STA
A
P
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BEI.OW). MINIMUM FEE
535.50.
BATH SINK/LAV FLOOR DRAINS ' SH�WER WATER PIPING
_ BATHTUB � _ GAS PIPING (NEED CJTY LIC) SWIMMlNG POOL WATER SOFTNER (S
_CC,OTHES WASHER _ KITCHEN S[NK � WATER CLOSET BACKFLOW PREV. SI )
_ DISHWA3HER _ LAUNDRY TRAY WATER HEATER (S35) FOR IRRIGATION
_ WATER METER OTHER
IS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
b apply for a ' g 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 appiication 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 ' e case of all work which requires review and approval of plans.
SIGNATURE OF APPLICAN��T ��ti "�L' ��•�>�j.�.yrYYIl�6�ii� PRINT NAM � L- l� C/ C f ,�SI �ATE �L J�7
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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