P - 47147Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE I-I-2011
DATE I� A� l'�e'Jt I YOUR E-MAIL ADDRES3
SITE ADDRESS -ri� l .7`iU _ ST • N�
THIS APPLICANT IS: O OWNER �CONTRACTOR
PROPERTY NAME: ` (�� G.� � � < < � ��
OWNER/ pDDRESS:�
TENANT
PHONE: %i7.�--
CONTRACTOR NAME: ��
SUBMIT A COPY OF
YOUR STATE STATE LiCENSE #_
LICENSE, BOND AND STATE BOND #�
CERTIF[CATEOF ADDR6SS: �I+�•
INSURANCE
, PHONE �Cj/ �—
PERMIT TYPE +�SINGLE FAMILY
TYPE OF WORK: I�'Cw
DETAILED DESCR[PTION OF WORK
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O TWO FAMILY
❑ REPLACEMENT
❑ TOWNHOUSE
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Permit No.:�vl ��%G-� s t
Received By:�\�
D��A�c'� �, '
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I � A STATE�I�ZIP_��j a
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EXP DATE
EXP DATE
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
� BATH SfNK/LAV FLOOR DRAINS '� SHOWER WATER PIPiNG
� BATHTUB _ GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KtTCHEN S1NK � WATER CLOSET BACKFLOW PREV. ($IS)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
TH[S IS AN APPLiCAT10N 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 th se o II �hich requires review and approv of plans. / J
SIGNANRE OF APPLICANT PRINT NAME �� �e��l% DATE_�( 1 a'� /� ��
.......,..... ..........�....,......,.......a. �..
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977