P - 45301Building PLUMSING
Inspections ��IDENTIAL APP�ICATI�.IN
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE�-�-�o�i
DATE '��s��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNERJ
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
❑ OWNER �
NAME: � i
ADDRESS: 4� �
PHONE: � I�
NAME: P � �
STATE LICENSE #
STATE BOND #
ADDRESS: � � G�
PHONE ��7 ` "l�
� SINGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
YOUP. E-MAIL ADDRESS
)NTRACTOR
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rt�j� � (�(� CITY�
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n �"� I�.� � � �x``1 cirY_
�-�� �i IdI�1 FAX
❑ TWO FAMILY
�REPLACEMENT
I] TOWNHOUSE
Permit No.
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EXP DATE
EXP DATE
T_STATE ZIP �r ��Z
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV PLOOR DRAINS SHOWER _ WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET _BACKFLOW PREV. ($15)
_ 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 ardinances and codes of th City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an ap lication for a ermit nd work is not to start without a permit on site; that the work will be in accordance
with the approved plan in � as of a r wh' h reyuires review and approva a� lans� �t/� r'
SIGNATURE OF APPLICANT PRTNT NAME 1= _�__DATE �
APPROVAL INSPECTORS SIGNATLIRE DATE
` City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977