P - 44847Building PLUMBING Permit No. =�� I�� l:� � ���
Inspections RESIDENTIAL APPLICATION Received By: '���
763-572-3604 CITY OF FRIDLEY D�(�'�:Crt
763-502-4977 FAX FFFECTivE�-�-ZOio
DATE��,�,
SITE ADDRESS �
THIS APPLICANT [S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
❑ OWNER 'gC(
NAME:
ADDRESS:
PHONE: �
NAME: � � Q ,� _� C�
STATE LICENSE #��
STATE BOND # _��
ADDRESS: �`��,t�%�
PHONE �la��' �-t 2� '
❑ SINGLE FAMILY
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
YOUR E-MAIL ADDRESS
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CITY STATE ZIP
;{�[]'°j EXP DATE ( L�Ji � LV 1 U
EXP DATE
CITY� r1 �� STATE�ZIP�
FAX ���Y 2�� I�p��
❑ TWO FAMILY ❑ TOWNHOUSE
� REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE 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 SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
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 c of all work which equires review and a pro t of plans ('}
SIGNATURE OF APPLICANT ��� �T S� PRINT N ATE �7 �
APPROVALINSPECTORSSIGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977