P - 41798Building
Inspections
763-572-3604
763-502-497'7 FAX
DATE � �
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY Np
OWNER/ A�
TENANT
PLUMBING
RE5IDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
YOUR E-MAIL ADDRESS '
- — �, r_ � _
❑ OWNER �,CONTRACTOR
CONTRACTOR NAME:�,,�.
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOPdD AND STATE BOND #
CERTIFICATE OF ADDRESS:
INSURANC!E
PHONE ��
PERMIT TYPE I �SINGLE FAMILY
TYPE OF WORK: I �NEw
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
❑ REPLACEMENT
Permit No. L1
Received By:
,
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_CITY ' i� 1 STATE lr�[P��
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' EXP DATE Z i I '
' EXP DATE
CITYI �I�i STATE I^ ZIP
_ F,�x 11��(� �S�D�-"
❑ TOV�NHOUSE
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL NUMBER OF EACH BELOW). M[NIMUM FEE �
$35.50. � ,
BATH SINK/LAV FLOOR DRAINS SHOWER WATER P[PING
BATHTUB GAS PIP[NG (NEED CITY LIC) SWIMMING POOL L 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 i
conformance with the ordinances and co es of the City of Fridley and with the Minnesota Construction Codes; that I understand this i
not a permit but only an application for permit and work is not to start without a permit on site; that the work will be in accordanc
with the approved plan in t rk which requires review and appro`v�1� f�?lans.
SIGNATURE OF APPLICANT PRINT NAME �/ l�l Y1�.�7 �=Gh� I�'DATE
APPROVAL INSPECTORS SIG ATURE
City of Fridley
Building Inspections Depat�tment
6431 University Avenue NE, Fridley,lVlN 55432
763-572-3604
FAX: 763-502-4977 '�
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