P - 35806.
.
Building
Inspections
763-572-3604
763-502-4977 FAX
DAT� � ° o�- - � °-
SITE ADDRESS c�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
XOUR E-MA]
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❑ OWNER �ONTRACTOR
Permit N
Received By:
Da d�
CONTRACTOR NAME: ����� �«�j�,g
SUBNIIT A COPY OF STATE LICENSE #
YOUR STATE # B') ZZn-PM EXP DATE
LICENSE, BOND AND STATE BOND # �-3�-1 +`34O EXP DATE
CERTIFICATE OF ,q�DRESS: �7� CITY STATE ZII'
INSURANCE
PHONE __ _ __ ' _ _ F�
PERMIT TYPE
TYPE OF WORK:
�,1 SINGLE FAMILY
�
!�.�1
DETAILED DESCRIPTION OF WORK
❑ TWO FAMII,Y
�REPLACEMENT
❑ 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 CITY LIC) SWIlvIIvIING POOL � WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTF�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 application a permit an o o to start without a permit on site; that the work will be in accordance
with the approved plan in.the case appr al of plans. y��, ���/ /
SIGNATURE OF APPLICANT T �C(i:hPS � ! � �(i1(J� DATE �� � r �
APPROVAL INSPECTORS SIGNA / �— / i.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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