P - 39803Building
Inspections
763-572-36Q4
763-502-4977 �AX
DATE� � � /� 1 �� I �
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SITE ADDRL�S � ai � "-
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRA.CTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-I-2010
NAME:
ADDRESS:
PHONE: I
STATE LICENSE #
YOUR E-MAIL ADDRESS
�
Permit No.: D�� �Qro G�� ��
Received By:��
���e'j�er��:G 14 2Q1Q
EXP DATE
'A
STATE BOND # DATE
ADDRESS: l�- I — Si �- cv�� ��/ CITY �STATE +"^-_ZIP S S
PHONE %G�^ S�G/ 3.��� FAX
TYPE OF WORK: I � ��'
FAMILY O TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EAC BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTLTB GAS PIPING (NEED CITY LIC) SWIMMING POOL ` WATER SOFTNER ($35)
CLOTHES WASHER +KITCHEN SINK J WATER CLOSET BACKFLOW PREV. ($15}
DISHWASHER LAUI�iDRY TRAY WATER HEATBR ($35) FOR IRWGATION
� WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D 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 wil] be in a cordance
with the approved plan in the �!� f� wor wh�quires review and approval of plans.
SIGNATITRE OF APPLICANT ��``� /'��� PRINT NAME �_/,j 1- L l_��l �� DATE �' �: 1%
APPROVAL INSPECTORS SIGNATURE %
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4477