P - 44544Building
Inspections
763-572-3604
763-502-4977 FAX
DATE " �-' "
SITE ADDRESS L
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
❑ OWNER'� V�GCONTRACTOR
ADDRESS
PROPERTY NAME: W CX�i(� 1n'C�i �'Gl.( %
OWNER/ �DxESS:
TENANT ��-7 ��
PHONE: �' 1 � O� 2
Permit No.:
Received By:
T&%�'��IP
coNT�cTOR rra,ME: C►,amAian o�..w.�:_ __
SU YO STOATE OF STATE LICENSE # #�� 770_Dn n EXP DATE
LICENSE, BOND AND STATE BOND # 6S �-3 - _ EXP DATE
CERTIFICATE OF ,�Dx�ss: 670 Dodd Rd. CTTY STATE ZIP
INSURANCE rxorr� an, 55123 Fax
PERMIT TYPE
TYPE OF WORK:
� SINGLE FAMILY
❑ rrEw
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIX'1'URES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (NEED C1TY LIC) SWIlvIlvIING POOL � WATER SOFTNER ($35)
CLOTHES WASHER KTTCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) 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 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 work will be in accordance
with the approved plan in the case of all work which requires review and approval of plans. ` )
SIGNATURE OF APPLICANT PRINT NAME DATE I� I ZJ 1'
APPROVAL INSPECTORS SIGNATUI�E ✓ _
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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