P - 48120Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-201 I
DATE � l
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
YOURE-MAILADDRESS l��e
❑ OWNER G�ONTRACTOR
NAME: .,� h.h �1 AI"�A�
ADDRESS: CITY
PHONE:
NAME: �S \ � � L` C
STATE LICENSE #_ � L(� C3 —'1 UV `
STATE BOND # % J�O
ADD�SS: faol'� �'�' e%i.�iSS S Crrv C
PHONE %�.3 0�,��_. p �Q � FAX
TYPE OF WORK: I� NEW
FAMfLY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
�'REPLACEMENT
=-��rfc 1�,.�� SFr� �
Permit No.:
Recei _� :�1 � �!Yf�
Date I�ec �
ATE ZIP.
EXP DATE I °��.3I �I �
�EXP D TE
_STAT�ZIP_ ���
FEES ARE BASED ON $10.00 PER FIX'I1JRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELAW). MiNIMUM FEE
$35.50.
BATH STNK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHNB GAS PIPiNG (NEED CITY LIC) SWIMMiNG POOL WA7'ER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($]5)
DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR fRR1GAT10N
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I hereby apply for a plumbing pennit and I acknowledge that the information above is complete and accurate; that the work wili 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 ll �ch requires review and approval of plans. �Q,�. /J
SIGNATURE OF APPLICANT � PRINT NAME ��v�u% �`i� S�'n DATE y�T ,�
APPROVAL INSPECTORS SI NAT E 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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