P - 47792Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �' p
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
g�--r��-
f' OWNER
EFFECTNE 1-I-2011
_ YOUR E-MAIL ADDRESS ``C' ���,a-�IS
Permit N
Received By
Date Rec'd:
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ur l� C r'�"'�
NAME: ✓c"� �i� �-ii/ �G p �sN <f � ��
ADDRESS: �� ��.� /� /��,� LL%?y CITY_ �-t�`��!'f�� STATE� ZIP ����-�
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PHONE: 76 � �-' �'``'l7 � %j �' �'
NAME:
STATE LICENSE #
STATE BOND # _
ADDRESS:
PHONE
�SINGLE FAMiLY
�'NEW
❑ TWO FAMILY
❑ REPLACEMENT
FAX
❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK _/ cJf �� ll �y7t�r.��lwy� 5..,y����
EXP DATE
EXP DATE
ATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH $ELOW). MINIMUM FEE
$35.50.
_ BATH SINK/LAV FLOOR DRAINS SHOWER � WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET � BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER 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 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 c�se� or � h r� e review and approval of pla}s. /�
SIGNATURE OF APPLICANT ,�� PRINT NAME_ ;�5'z°'9�1�1��C,�GL�f DATE_ �� l�'� ��
APPROVAL INSPECTORS SIGNAT RE DATE
„ _
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977