P - 48167Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � I 7 �� �'
SITE ADDRESS J�3
THIS APPLICANT IS:
PROPERTY N�
OWNER/ �
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
/Lt �o�v .J� .
❑ OWNER �CONTRACTOR
� Gf-
,: 53� I�,�/z�or�- .�7,� ci�
Permit No.:
eceived�B��
Dai� Rec d:
T�,G�� 5'
PHONE:
CONTRACTOR NAME: ��/� �Qti �Gv/`1��
SUBMIT A COPY OF STATE LICENSE # Ob 1 O 3 J � EXP DATE � � ���
YOUR STATE
LICENSE, BOND AND STATE BOND # EXP DATE
CERTIFICATE OF ADDRESS: CITY STATE ZIP,
INSURANCE pHONE (O �Z' %O� '" � F�
PERMIT TYPE I �SINGLE FAMILY
TYPE OF WORK: I � ��'''
DESCRII'TjON OF WORK
0
❑ TWO FAMILY ❑ TOWNHOUSE
�LACEMENT
�// , �c�i.Z�°� dif/C� � �.�% �1,e�L
�
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
Z BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
'� BATH1'[JB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
� CLOTEIES WASHER 7 KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
DISHWASHER L LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
— WATER METER OTI�R
I hereby apply for a plumbing
conformance with the ordinan�
not a permit but only an app��
with the approved plan in th ` c
SIGNATURE OF APPLICAN���
APPROVAL INSPECTOSgSI N?
�
THIS I APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 I o ge that the ' formation above is complete and accurate; that the work will be in
ccjd s f the Ci of Fri ey d with the Minnesota Construction Codes; that I understand this is
o rmit and rk 's n to start wit t a it on site; that the work willp e i�f accordance
1 k which req ' es view and app� ���� �//�/����
,. vvrnrr�Ter,r��"A i iIATF.
U City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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