P - 60328Building
Inspections
763-572-3604
763-502-4977 FAX
DATE� ( � �-
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SITE ADDRESS
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFEC7TVE 1-]-2012
�� YOUR E-MAIL ADDRESS
O OWNER ❑CONTRACTOR
OWNER/ ADDRESS:
TENANT
PHONE: �y� �'
CONTRACTOR NAi,,t�: �DS �
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #_
LICENSE, BOND AND STATE BOND #
CERTIFICATE OF ADDRESS: 12S ;
INSURANCE pHONE ��7 •--`Z
PERMIT TYPE
TYPE OF WORK: I � �W
FAMILY
DETAILED DESCRIPTION OF WORK
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❑ TWO FAMILY
REPLACEMENT
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CITY �"�^� �1. l ��/ STATEII'INZIP_
EXP DATE
EXP DATE
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FAX
O TOWNHOUSE
FEES ARE BASED ON SI0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELQW). 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 IRRIGATTON
_ 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 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 the case of 1 w•k h' h requires review and approval �lans,�h `/'� `
SIGNANRE OF APPLICANT PRINT NAME � SG�, `�G�I//P� � DATE / �� r Z
APPROVAL INSPECTORS SIGNA ____ DATE
City of Fridley
Building Inspections Department
6431 Universiry Avenue NE, Fridley, MN 55432 .
763-572-3604
FAX: 763-502-4977
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