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Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE / ._ y °
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
1NSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
� /�(G �iitidY+�t ovt �' /,/�
❑ OWNER ❑CONTRACTOR
Received By;
Date Rec'd;l
NAME:
ADDRESS: CITY STATE ZIP
PHONE:
NAME: G/ �i%t �/l U Lvt (O t ti[q�
STATE LICENSE # � I�I' .S S� ��% EXP DATE �
STATE BOND # D�% ��9 % EXP DATE
ADDRESS: � Z% p`Z S� CITY .� ovt� aw � STATE�K ZIP SS�S 2
PHONE �,/� � " �� S/ ,. S'" % � FAX
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
FEES ARE BASED ON $I0.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FL�R DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED CITY LIC) _ SWIIvIIvIING POOL WATER SOFTNER ($35)
_ CLOTI�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER (S35) FOR IItRIGATION
_ WATER METER _ OTf�R
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 nd with the Minnesota Construction Codes; that I understand this is
not a permit but only an application fo a permit and work is no , to start without a permit on site; that the work will be in accordance
with the approved plan in the , equir r iew an��ppro}�1 o�plan� ,
SIGNATURE OF APPLICANT . PRINT N N�--�[-o-( �u./� DATE /— y �i
APPROVAL INSPECTORS S N E }yp�� Dp� / �. � �
City of Fridley
Building Inspections Department
6431 Universiry Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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