P - 60371Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `1'��I Z
SITE ADDRESS ��
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
O OWNER �3CONTRACTOR
PROPERTY NAME: V V�'i,f��'PJ� �/�I (}O�5
OWNER/ �DxESS: ��r� �
TENANT pHONE:T� � °" � -� Z� � O
Permit No c
Received B
CONTRACTOR NAME: Champion Plurrtbin�
SUBMIT A COPY OF STATE LICENSE # # 61770-PM EXP DATE � Z' (�
Youx sTa� 651-365-1340
LICENSE, BOND AND STATE BOND # EXP DATE _
CERTIFICATE OF �DRESS: � ' CITY STATE zIP
INSURANCE pHONE ' FAx
PERMIT TYPE
TYPE OF WORK:
�7 �SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
C��' EPLACEMENT
�
FEES ARE BASED ON $10.00 PER FUYTURE, EXCEPT WHERE NOTED. FIXT'[JRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/I,AV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIIvIMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LALTNDRY TRAY LWATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply fof a plumbing pe d I acknowled� e that the information above is complete and accurate; that the work will be in
conformance with the ordinances and co of the Ci of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application a per 't w ot to tart without a permit on site; that the work will be in accordance
with the approved plan in the case r i r a approv 1 of plans. /? ���,� �
SIGNATURE OF APPLICANT _� PRINT NAME _�Q� la •�_/"��A� �' �`� Z
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
lui�