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Building PLUMBING Pernlit rlo.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate Rec'ct: 3 t
763-502-4977 FAX EFFECTIVE 1-1-2012
SIT'E ADDRESS _
T'HIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS _
❑ OWNER ❑CONTR.ACTOR
NAME ��i� � � .Ssif c��0/� e'
ADDRESS: CITY Y'�
PHONE:
STATE LICENSE t�_
STATE BOND # _
ADDRESS:% QU
PHONE �
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
K,T I 7T.�=�'►'rl
UJ✓ . r
❑ TWO FAMILY
� REPLACEMENT
a`re,r 1��•�-%�✓
EXP DATE
EXP DATE
_CIT'Y���+✓�
_ FAX
❑ TOWNHOUSE
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��_�
TE�ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50. WATER PIPING
BATH SINK/LAV _FLOOR DRAINS _ SHOWER _
— g,��g _ GAS PIPING (NEED CITY LIC) _ SWIMMING POOL _ WATER SOFTNER ($35)
CLOTF�S WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
— — W ATER METER _ OT[�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 co of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an app c tion fo p it work i tart without a permit on site; that the work will be in accordance
with the roved lan in c e equires review and appr�'a�l �jf� plans. G
SIGNATURE OF APPLICANT PRiNT NAME *'►��T"rt0�1 �er �%I� DATE "
APPROVAL INSPECTORS SI A URE �� DA�
V City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977