P - 36936Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ! ( �
SITE ADDRESS �OJ.) � LL1,GI �
TH1S APPLICANT IS:
Y
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EFFECTNL 1-1-2011
❑ OWNER
PROPERT NAME�
OWNER/ qDDRESS:
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
YOUR E-MAIL ADDEtESS
- � �'c� - �
NAME: I �
STATE LICENSE #
STATE BOND #
ADDRESS:�G 1D /�uvl� �� �'� CITY _
PHONE ��-�� /�1,� FAX
PERMIT TYPE I �INGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
O TWO FAMILY ❑ TOWNHOUSE
Y�REPLACEMENT
Permit No.
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�:' �� �
A'
EXP DATE
EXP DATE
� STATE�/ ZIP ,S�S �L
'�_ �.��_ %s%li�t
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH $ELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY _, j_WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
1
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the wark 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 wark will be in accordance
with the approved plan in the /a.f,�1] w 1 hi requires review and approv of� �lans /,,� �1 p
SIGNATURE OF APPLICANT G�//� ��� _ � . PRINT NAME / I �fL- Gl "�7l�DATE L l�
APPROVAL INSPECTORS SIGNATURE /� DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977