P - 37125Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 2� �'I �
SITE ADDRESS 2�
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
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❑ OWNEK �lCONTRACTOR
Permit No.:
Received By:��_�-
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PROPERTY �1AME: ,� �k tn� t.� t�'
OWNER/ ADDRESS: LCI^�?L�� CITY ����•'! STATE��IP ���'J�`�
TENANT pxoNE: (o yJ" � — l���
CONTRACTOR NAME: rw�,�«.,�',,,� �t,,,M,l�,i�n
SUBMIT A COPY OF
YOUR STATE STATE LICENSE # # 6�i 77�PM EXP DATE
LICENSE, BOND ANl) STATE BOND #__.____ ____ �_rJ__� -�G 'rJ_`.1 �4O ._ EXP DATE
CERTIFICATE OF ADDRESS: 36%O DOCICI RCJ. CITY STATE ZIP
INSURANCE pHONE �g�n' FAX
PERMIT TYPE
TYPE OF WORK:
�INGLE FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK �Q�(�,�� �J ���(� t-c.yuC..i�
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FEES ARE BASED ON $10.00 PER FIXT[JRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NLJMBER OF EACH BELOV�. MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL � 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 LTNTIL 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 ardinances 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 case ,of �1L •1 w1.' r v'ew and ap ov 1 of plans. �t
SIGNATURE OF APPLICANT 4�u�������� f'��M -.�- C- DATE Z� Z T�� (�
APPROVAL INSPECTORS SIGNA � , ��
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-497?
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