P - 41797Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ' � � ! (
SITE ADDRESS �
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
l r r Zo� `D�_
❑ OWNER �ONTRACTOR
PROPERTY NAME:_
OWNER/ ADDRESS:
TENANT
Permit No.:
Received By:
CITY STATE ZIP 5�'I f
CONTRACTOR N�:
SUBMIT A COPY OF •
YOUR STATE STATE LICENSE # #,��'7��, EXP DATE
LICENSE, BOND AND STATE BOND # �j5i �,'j�-1$�LO EXP DATE
CERTIFICATE OF �DRESS: :3B7O DOCiCI R4%• CTI'Y STATE ZIP
INSURANCE
PHONE ES�it MN 55 Fa�c
PERMIT TYPE
f r_`l���I�I�i�I�7:i:4.
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
L�REPLACEMENT
`_��"
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�: MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PII'ING (NEED CTTY LIC) SWIMMING POOL WATER SOFTNER ($35)
� CLOTf�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
, DISHWASHER _ LAUNDRY TRAY �' WATER HEATER ($35) FOR IItRIGATION
� WATER METER OTE�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 ity of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c f all wo c es review and appr val of pians. n^ / �_�� � �
SIGNATURE OF APPLICANT i�iJ%%/% . T NAME� CR/YYiC� C7 1 I 1 PA�PA DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604
FAX: 763-502-4977
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