P - 42358Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
.-
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2010
� YOUR E-MAIL ADDRESS
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❑ OWNBR �' S�ONTRACTOR
CONTRACTOR " �'
NAME: / � I� YL.t��i
SUBMIT A COPY OF
YOUR STATE S7'ATE LICENSE #
LICENSE, BOND AND STATE BoND # s
CERTIFICATE OF ADDRESS: �7Ci �r�
INSURANCE pHONE O �l - .a� ��D � 1
PERMIT TYPE
TYPE OF WORK: I d NEW
0
FAMILY ❑ TWO FAMILY
DETAILED DESCRIPTION OF WORK
CiTY
i�
Permit No..�
Received By:
D�����
A
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' �� EXP DATE "�G�
� EXP DA�T'E
' ✓� '7� /CITY lC ��O �/L STATElN ZJP "`rj S �
FAX .
�REPLACEMENT
❑ TOWNHOUSE
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FEES ARE BASED ON $10.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOQR DR.AINS SHOWER WATER PIPiNG
BATHTfJB GAS PIPING (NEED CITY LIC) SWIMMING POOL ` WAT�R SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK ^ WATER CLOSET ' BACKFLOW PREV. ($15)
_ DISHWASHER � LAUNDRY TRAY WA7ER HEA'I'ER ($35) FOR iRRIGAT]ON
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID L1NT'IL PROCESSED
I hPreby 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 withovt a permit on site; that the work will be in accordance
with the approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT L���.�_ PRINT NAME � J �f'Ic'J/ `-`rI DATE ��� /
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977