P - 35780Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ( Z 7 � C71 �
SITE ADDRESS TG�O
TH1S APPLICANT IS:
PROPERTY NAME:
OWNER/ ADDRE
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS �� `? � G�Ca�.7 (�/ ✓YI
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❑CONTRACTOR
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CITY
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Permit No.: �
Received By:_
�l�t� R�t�c�- '
C c�:
STA
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # EXP DATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: CITY STATE ZIP
iNSURANCE �
PHONE FAX
PERMIT TYPE ,�: SINGLE FAMILY
TYPE OF WORK:
DETAILED DESCRIPTION OF WORK i n
� TWO FAMILY
❑ REPLACEMENT
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❑ TOWNHOUSE
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�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
�TEISINK/LAV FLOOR DRAINS SHOWER WATER PIPING
��ATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($IS)
_ 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 codes 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 permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the ca 11 w k which requires review and approv of lans. _/� / �-7
SIGNATURE OF APPLICANT '��(''� PRINT NAME �-cn,��: oniln O l�Crx-n DATE �[ Z//ZV �I
APPROVAL INSPECTORS SIGNATU ne�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
'763-572-3604
FAX: 763-502-4977