P - 417940
Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECT� �-i-2oio
DATE L' 1 "�'""
SITE ADDRESS ��(,
THIS APPLICANT IS:
PROPERTY
OWNER!
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
NAME:�� �� � O �f C� .�GiLGL17
nDD�ss: Sc�.rY,Q� ci�
PHONE:��� ' ZZ� �_
STATE LICENSE #_
STATE BOND #
ADDRESS:�
PHONE I'�
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
' CITY_
FAX
❑ TWO FAMILY
�4tEPLACEMENT
�►n�� . w ��t
❑ TOWNHOUSE
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SS43
EXP DATE L�L-�I 1
EXP DATE
U' Xl STATE;��ZIP S�3
FEES ARE BASED ON $10.00 PER FIX'1'URE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi�. MINIMUM FEE
535.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CTTY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTI-IES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IItRIGATION
WATER METER OTI�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iTNTIL 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 code f the City Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe 't and rk ' not to start without a permit on site; that the work will be in accardance
with the approved plan in the case of,a�����%�;�yh ,�-�pproval of plans. . +� _� s��_
SIGNATURE OF APPLICANT � � T NAME __. ___ ___ DATE L'
�% City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604
FAX: 763-502-4977
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