P - 60278Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�LII1 (�
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:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
F.FFEC7'IVE 1-1-2012
YOUR E-MAIL ADDRESS
� �� � � l_J�
❑ OWNER COP
NAME: 1 � L � GYiCL
ADDRESS: � � I � GG
PHONE� 1 IO :+ "� Z�L� "
Permit No.:
Received
STATE LICENSE #�C v EXP DATE �
STATE BOND # q 2"1 � �C1 "1— EXP DATE �
ADDRESS:.��� I�CaI K a���Y ) �� CITY �� U`
PHONE (ll��� ��� I FAX �� 1 � Z�
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMJLY ❑ TOWNHOUSE
I�'REPLACEMENT
�� - �l y � � �
.
ATE�1/.��ZIP r'J�3�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED: FIX7'URES: (INDICATE TOTAL NUMBER OF EACH SELOW). . MININIUM FEE '
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER _ WATER PIPING
BATHTUB GAS PIPING (NEED C1TY 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 cod 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 p it and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in th e of all w hic requires review and approval of plans.�°
SIGNATURE OF APPLICANT � PRINT NAME �� l`ilG Y� (7'C� DATE
APPROVAL INSPECTORS SIG AT DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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