P - 84374Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � � ` � �
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY NAME:
OWNER/ pDDRE
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY UF FRIDLEY
EFFECTIVE I-]-2012
❑ OWNER
PHONE:
NAME: i
STATE LICENSE #
YOUR E-MAIL ADDRESS
dsy �/ �
Permit No.:� �a'v� �'�
Received By:�_
Da��' : '� � .
EXP DATE
ATP�'�h Z1P S�
STATE BOND # EXP DATE
ADDRESS:/O �%/� /Lj/SJ/�'��v�� ��t��_CITY ���7 /�i4���% STATEI'"�/'+ ZIP S""S'7�Y
PHONE 1eL,�-.% y Z'���-�% FAX
..�SINGLE FAMILY
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DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY 0 TOWNHOUSE
❑ REPLACEMENT
w.r� �1
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW).
� BATH SINK/LAV FLOOR DRAINS I SHOWER _ WATER PIPlNG
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
TH1S tS 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 o the City of Fridley and with the Minnesota Construction Codes; that 1 understand this is
not a permit but only an applic on a p it and work is not to start without a permit on site; that the work wiil be in accordance
with the approved plan in th e which requires review and approval of�? lans.
SIGNATURE OF APPLICANT . PRINT NAME S��'`� V�4arr5�'�'�- DATE /D -/�i - I Z--
APPROVAL INSPECTORS SIG TURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977