P - 44636Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CIT� OF FRIDLEY
763-502-4977 FAX EFFECT►ve �-�-zo�o
DATE ` �� Y. UR � AIL A�S
S[TE ADDRESS At�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR '
PROPER Y NpME: ("'1.
T NA N ADDRESS: V�.,� � CITY �
� PHONE��O� ��] � Q�i `�� I
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #
LICENSE, BOND AND STATE BOND #�
CERTIFICATE OF ADDRESS:�
INSURANCF.. pHON� � `� %
PERMIT TYPE SINGLE FAMILY
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TYPE OF WORK: � NEW
DETAILED DESCRIPT[ON OF WORK
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❑ TWO FAMILY
�EPLACEMENT
FAX
❑ TOWNHOUSE
Permit No.: �
Received By:
D�t;T�_ l��
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S �ZIP��� �`�ti�
EXP DATE � t � I
EXP DATE � I
�STAT�_ZI
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED: FIXNRES: QNDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE '
$35.50.
_ BATH SINK/LAV FLOOR DRAINS SHOWER � WATER PIPING
BATHTUB ^ GAS PIPING (NEED CITY LIC) _ SWIMMING POOL � WATER SOFTTIER ($35)
_CLOTHES WASNER KITCHEN SiNK WATERCL�SET BACKFLOW PREV. ($IS)
_ DISHWASHER , LAUNDRY TRAY ^WATER HE?�TER ($35) i FOR IRRIGATION
^ WATER M�TER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D UNTIL PROCESSED � I
1 hereby apply� for a plumbing permit and i acknowledge that the information above is complete and accurate; that the work wil{ be i
conformance with the ordinances and codes of the City of Fridley and with the Mit�nesota Construction Codes; that I understar�d this i
not a permit buU only an application for a permit and work is not to start without a permit on site; that the work will be in accordanc �
with the a roved lan in the case wo r uires reviey� and a rov I of lans. �/r,(f
SIGNATURE OF APPpICANT RINT NAME �� �����-�"l."'6�TE
APPROVAL INSPECTORS SIGNATURE �, t� ,. -_ �_
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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