P - 37227Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I � � � o�- - � O
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
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❑ OWNER
YOUR E-MAIL ADDRESS
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C�CONTRACTOR
Permit No.:
Received By:f 1 � n
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ADDRESS: CITY STA'3'E ZIP,
CONTRACTOR NAME:�'1 �2
SUBMIT A COPY OF STATE LICENSE
YOURSTATE
LTCENSE, BOND AND STATE BOND #_
CERTIFICATE OF p,�D ; � C�
INSURANCE pHONE '��' S
PERMIT TYPE
TYPE OF WORK:
�INGLE FAMILY
❑ NEW
'AILED DESCRIP N !OF WORK
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/�'/ I` F'Y l`'' EXP DATE
EXP DATE
t3 ai ��1 Q�1i.,1 ��C.1 CITY � ti�.—
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❑ TWO FAMILY � TOWNHOUSE
❑ REPLACEMENT
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ATE��ZIP.
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) SWIMMING POOL WATER SOFTNER ($35)
CLATHES WASHER KITCHEI3 SINK WATER CLOSET � BACKFLOW PREV. ($15}
�ISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER � OTHER �('.,Q ��� y�
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 a� plicatio f permit d work is not to start without a permit on site; that the work will be in accordance
with the approved pla�in e f hid�i requir review and appr�J��1 o plans� If �,�)� i j
SIGNATURE OF APPLIC �.� PRINT NAME Y V L<C�-�Y�' �` Q�� �I[..7� K DATE � l' ��� (U
APPROVAL II3SPECTORS SIGNATURE _ _
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
F.AX: 763-502-4977
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