P - 48567Building
Inspections
763-572-3604
763-502-4977 FAX
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SITEADDRESS �.
THIS APPLICANT 1S:
PROPERTY
= OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
O OWNER
YOUR E-MAIL ADDRESS
CI7'Y
PHONE:
NAMETSP�/y�n'J /�ITC haYVL
STATE LICENSE # G �, b 5 7 Q"
Permit No.
Received By:
,._._
� �
EXP DATE
TE ZIP
STATE BOND # EXP DATE
ADDRES • � 1� F!' CITY C�'a'L �%j/�I STA'I"E�ZIP��
PHONE �IG'? � �" Ci �lli i FAX
PERMIT TYPE I�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I � �w �PLACEMENT
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$ 5 0.
;�ATH SINK/LAV _FLOOR DRAINS �HOWER _ WATER PIPING
BATH'TCTB �AS PIPING (NEED CITY LIC) �WIMMING POOL WATER SOFTNER ($35)
'�LOTF�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
ISHWASHER _ LALTNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTf�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a plumbing permit and I acknow dge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and code the i of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe it work is not to start without a permit on site; that the work will be in accordance
with the approved plan i of all w i h equires review and approv 1 of ans. .��1���
SIGNANRE OF APPLICANT PRINT NAME d'► �"7dDb DATE � 1"l/ I�
APPROVAL INSPECTORS SIGNATURE L i DATE 3-<<-� 2
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977