P - 35449Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � I 'l �
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
E-MAIL ADDRESS
SITE ADDRESS �1.� `-�"_T� ��_��"1 , 1`-'L
THIS APPLICANT IS: ❑ OWNER f�CONTRACTOR
PROPERTY �A�.�
OwNER/ aDDxESS:
TENANT .
Permit No.:l� 1`
Received By: ' I��
��tee!�� 2 0 2�
CONTRACTOR NAME: Champion Plumbin�
SUBMIT A COPY OF STATE LICENSE # # G� �%O-PM EXP DATE
YOUR STATE
LICENSE, BOND AND STATE BOND # 4 EXP DATE
CERTIFTCATE OF �DRESS: r_�.�_ ��w � r_ r_ a nrCTfY STATE ZIP
INSURANCE pHONE � FAX
PERMIT TYPE
TYPE OF WORK:
� SINGLE FAMII..Y
0 NEW
DETAILED DESCRiPTION OF WORK
❑ TWO FAMII,Y
C�REPLACEMENT
�e� G..QCt�-C,
❑ TOWNHOUSE
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
� BATHTUB GAS PIPING (NEED CTTY LIC) � SWIMMING POOL WATER SOFTNER ($35)
CLOTHES 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 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 applicatio a permit d w• c is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c 1 � �uv�d appr qva� f pl� f ,'" ]
SIGNATURE OF APPLICANT PRINT NAME J �DATE ���( I
APPROVAL INSPECTORS SIGN
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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