P - 39992� _
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �' I �-
SITE ADDRESS i � �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
YOUR E-MAII, ADDRESS
❑ OWNER �ONTRACTOR
CITY
Permit No.: lQ
Received By:
� . i;. s't ��
STA'
CONTRACTOR Nn�: Champion Pl�mhina
SUBMIT A COPY OF STATE LICENSE # #' B� %%O^PM EXP DATE 12- ((
YOUR STATE 65'I -365-1340 EXP DATE _ I Z-�
LICENSE, BOND AND STATE BOND �_. —�—
CERTIFICATE OF �DRESS: � ' CITY STATE ZIP
INSURANCE PHONE ' F�
PERMIT TYPE
TYPE OF WORK: � a rrsw
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
.�R�PLACEMENT ~
� r�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXT'URES: (INDICATE TOTAL NUMBER OF EACH BELOV�. NIINIMtJM FEE
$35.50. ,
BATH SINK/LAV _FLOOR DRAINS SHOWER _ WATER PIPING
� BATHTUB GAS PIPING (NEED CTTY LIC) SWIIvIlVIING POOL WATER SOFTNER ($35)
CLOTF�S WASHER KITCHEN SINK WATER CLOSET _BACKFLOW PREV. ($15)
DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IltRIGATION
' WATER METER ' _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII, 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 f Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for rmit a o is start without a permit on site; that the work will be in accordance
with the approved plan in the case of al ' ' v�f plans. _ q
SIGNATURE OF APPLICANT NAME �/1�.-S ��, �1�DATE 1 ' ( �--" � �
APPROVAL INSPECTORS SIGNATURE
`�V City of �ridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
) �5�s
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