P - 36956Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ��
STTE ADDRESS �
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7—]-2010
I�ONTRACTOR
PROPERTY NAME:� I b ��E" C V�%dI�
OWNER/ nDD1tESS: 'cy�t�►'1'°
CITY
TENANT
PHONE: (D �� ' � '
Pe��t No.:
Received By:l � �K �
��IJKe��� U � ���
CONTRACTOR NAME: � ��n Plumbin�
SUBMIT A COPY OF STATE LICENSE # 17%Q—PM EXP DATE
YOUR STATE # ��
LICENSE, BOND AND STATE BOND # BJ� —.3�J-13�:0 EXP DATE
CERTIFICATE OF ,a,DDx�ss: 3670 Dodd R. crrY sTa� z�
INSURANCE pHONE �• FAX
PERMIT TYPE
TYPE OF WORK:
�CSINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMII.Y
�REPLACEMENT
❑ TOWNHOUSE
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED: FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PII'ING (NEED CTTY 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 iTNTIL 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 pe� an work 's not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of i � 7 pproYal of plans. �_
SIGNATURE OF APPLICANT �T 1NAME vJGf/Vv���' (�� ��'►�' �� DATE��` ��/
APPROVAL INSPECTORS SIGNA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-360�1
FAX: 763-502-4977
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