P - 36707Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / �' �f, -- / O
SITE ADDRESS ���D -t
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
DETAILED DESCR]
��.G✓��YN
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
Permit No.:
Recei�c�;�y:
rt�t, u
Date Rec'd:
YOUR E-MAIL ADDRESS `� � %�� !��/� -ri ( .�t/��0. � �� lyl.. \
❑ OWNER j�CONTRACTOR
ADDRESS:
PHONE:
1VHNlb: L"'�l�Lr—
STATE LICENSE #_
STATE ZIP,
EXP DATE �a - 3i - � �
EXP DATE � a- - � / - / I
PHONE%6 xJ "�8� - 4� 4� FAX
�INGLE FAMILY ❑ TWO FAMILY O TOWNHOUSE
O NEW
OF WORK
�tEPLACEMENT
FEES ARE BASED ON $10.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELAW), MINIMUM FEE
$35.50.
�BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
� BATHTUB ✓ GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER (�35)
I CLO'fHES WASHER _[_, KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS}
1 DISHWASHER LAUNDRY TRAY _WATER HEATER ($35) � FOR IRRIGATION
^ WATER METER OTFiER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 th City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an ap ation for a pe ' and work is not to start without a permit on site; that the work wil] be in accordance
with the approved plan in th/c e of all wor c re ' e�,, view and ap val of plan �,�,�i�[/�,
SIGNATURE OF APPLICANT � 6 � � � T NAME L�( � ���G� E%(�'C°. DATE � � � � '�C7
APPROVAL INSPECTORS SIG ATURE II,L _
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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