P - 48169Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �h �
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
O (/ / �� YOUR E-MAIL ADDRESS _
/5L� S�`
❑ OWNER �ONTRACTOR
NAME: r% � �
ADDRESS: OC� c, d 1'( �
PHONE: � �� h � ���
NAME: , �'/?'L�Jv' e C �`- /�C w
STATE LICENSE #
Permit No.:
Received By:
D��i�'di �1 �! � % C �I
EXP DATE
STATE BOND # EXP DATE
ADDRESS: CITY S�G v✓ f%{_ STAT ��ZIP
PHONF�I+�-�—��,?rri - O%•/ � FAX
TYPE OF WORK: I � �"�'
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK � r-' zr G LY �/�-� �'' ��� !4' �' .�U �O r'iP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MII�IMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMIvIING POOL WATER SOFTNER ($35)
CLATf�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
— _ VJATER METER _ OTHER
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 Fridiey 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 'n the c�j of ich reyuires review and a��� of pl�` ^�
SIGNANRE OF APPLICAN�T'--T/ ' -�-� PRINT NA�vlr;/ �/l,'/<�!//'� �� DATE�� /,�
APPROVAL INSPECTORS RE _ �_�-' 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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