P - 44845Building
Inspections
763-572-3604
763-502-4977 FAX
DATE "(�
SI7'E ADDRESS �
THIS APPLICANT !S
PROPERTY NAME:
OWNE'R/ ADDtz�s
TENANT
PLUMBING
Permit Na:��� �
RES.IDENTIAL APPLICATI�N Rece��ed sy:�` '
CITY OF FRIDLEY Da��'���
EFFECTTVE 1-I-2010
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�.vi� i nr►�. i va� NAME: �
SUBMIT A COPY OF
YOL3R STATE STATE WCENSE # � EXP DATE
LICENSE, BOND AND STA'J'E B011D N '� EXP DA'iE
cER�n�cAr� oF AD�ss: a opee� STATE Z1P
INSURANCE pHONE 9�-4LLr'J-�HO3 FAX
^
PERMTT TYPE
TYPE OF WORK: ' � ��
FAMILY ❑ TWO FAMILY D TOWNEiOUSE
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON S I O.QO PER F[7C7LtRE, EXGE�7' WfiERE NOTED. FiX"NRES: (TMDtCATE TOTAL MltviBER 4F EACH BELOW). MINIMUM FEE
535.50.
BATH SINKJLAV Fl,OOR DaLA(NS SHOWER WATER PIPING
~ BATHIUB GAS PIPING (NEED CITY UC) SWIMMING POOL WATER SOP1TIER (S35)
CLOTHES WASHER KITCHEN SINK � WA'PER CLOSET � BACKFLAW PREV. (SiSj
� DISHWASH6R � LAUNDRY TRAY ,, ,_,WATER HEATER (S35) FOR IRRIGATION
` WAiER METER ` OTHER
�
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
!
I hereby apply for a plumbing permit and I acknowledge that the information above is compiete 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 wil� be in accordance
with the approved pian in th ase af all w� which quires rcview and approv,al of plans.
/� �% ' �/�q �l p ` a
SIGNATURE OF APPLICANT �� {�I' �� x � � �' PRINT NAME <��{'Y d � L � �t.� DATE � ' �
—i � ---c--T—r� �
. City of Fridley
� • Building Inspections Department ,
6431 University Aventae NE, Fridlep, MN 55432
- 763-572-3604
FAX: 763-502-4977