P - 44552Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SU$MIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
ADDRESS
❑ OWNER �CONTRACTOR
ADDRESS: S C�y` � CITY
rxorrE: `-�-iP � �O
Permit N
Received By:
STATE LICENSE # # g� 77�rM EXP DATE 1 a- 5l ��
STATE BOND # EXP DATE I' �
ADDRESS: r_.,.�.. ��w� ��i ��crrY STATE ZIP
PHONE ! FAX
PERMIT TYPE I�SINGLE FAMII,Y ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I❑ tvEw �xErLaCE�rrr
DETAILED DESCRIPTION OF WORK VV(A�,V �(l_Q��,d%�`9�.-C.Lv��n%`�"`
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMiJM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIl'ING
BATHTUB GAS PIl'ING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTEIES WASHER KTTCHEN 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 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 p� it and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the cas a� worle v ch �fk,�vi and appr val of plans.
SIGNATURE OF APPLICANT ��� T NAME ` C_ _ �`� �� DATE I
APPR(1VAi. iNCPFC'T(1RR CTrN . . � 1��"` F/
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604
FAX: 763-502-4977
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