P - 44829,.
Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER 1'�,�ONTRACTOR
ADDRESS: /'_ � � CITY
PHONE: �ll1 -��" r -
Permit No.
Received By:
� �'� �
ATF�1 GIP,
STATE LICENSE # # 61770-PM EXP DATE i a- 3 i� � �
sTaTE sorm # 651-365-1340 EXP DATE ( C7Z" 7` `�(
ADDRESS: ^ � ' CITY STATE ZIP
PHONE ' FAX
�SINGLE FAMII.Y
���
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
[�'REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MtNIMUM FEE
$35.50.
BATH SINK/LAV _PLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CTTY LIC) SWIMMING POOL � WATER SOFTNER ($35)
_ CLOTF�S WASHER KITCHEN SINK . WATER CLOSET BACKFLOW PREV. ($IS)
_ 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 applicatiQn 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 1 ork � �'�re revie and approv 1 of plans.
SIGNATURE OF APPLICANT � � �����T NAME ,►,Y„oS (� Me�ATE I' S�� 1
APPROVAL INSPECTORS SIGNA -% �- / ' �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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