P - 43787Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE I-I-2011
DATE � // � '
SITE ADDRESS �
THIS APPLICANT iS
PROPERTY
OWNER/
TENANT
2� (
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
L[CENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS L7 i�v v� 1/►1q i
O OWNER E�ONTRACTOR
ADDRESS: f�%Z 1.�ak�n Pa-�Cw�+.,,, CITY,
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PHONE:
STATE LICENSE #_
STATE BOND !i
ADDRESS:
PHONE � '
�SINGLE FAMILY
�NEW
DETAILED DESCRIPTION OF WORK
O TWO FAMILY
❑ REPLACEMENT
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Permit No.:�UVI UCJ�45-�
Received By: _
Da d < . _ . � �
��G� �a� - c �w.
STATE�'IP��� �
` EXP DATE
�— EXP DATE
_� iL .�n,�etire.l�.va
FAX
❑ TOWNH0113E �
4
�OtI�
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE N�TED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
�$3 .50.
A7H SINK/I,AV FLOOR DRAINS ,�SHOWER WATER PIPING
_ BATHTUB GAS PTPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_CLOTHES WASHER KlTCHEN SINK �' WATER CLOSET BACKFLOW PREV. ($t5)
_ DtSHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR [RRIGATION
_ WATER METER _ OTHER
9
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and [ acknowledge that the information above is complete and accurate; that the work will be in
conforntance 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 applic tion 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 of w} w ich r uires review and appro I off�l�ans / / )�
SIGNATURE OF APPLICANT �_PRINT NAME �rt n?" �h�'Gh`^� � DATE / V� �"1 ��J' �
APPROVALINSPECTORSSlGNATURE neTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977