P - 47947Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE i-1-2011
DA'TE / ` j (/7 /'L
S[TE ADDRESS ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTTFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
d
❑ OWNER
NAME:
ADDRES
PHONE:
NAME: ti� �
STATE LICENSE # ' �
STATE BOND # %9/i/;
ADDRESS: �!3 � � ��
PHONE 7�`-� asy ;
FAMILY O TWO FAMILY
DET�ILED DESCRIPTION OF WORK
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CITY
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FAX
❑ TOWNHOUSE
� REPLACEMENT
Permit N
Received By:��__
, ' �
Dat���. _ � . ��
� � MQic-t N� cs�rr�
STATE ZIP
EXPDATE 1�i.3�"'"'���a
EXP DATE �a �� � – aL�C�
ATE �NZI P�3
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
�?C��ATH SINK/LAV —FLOOR DRAINS i%CSHOWER = WATER PIPING
�SATHTUB GAS PIPING (NEED C[7Y LIC) SWiMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER KITCHEN SINK RWATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRR]GATION
WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VAUD 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 f or hich requires review and approval of plans. ('� j�,,,.
SIGNATURE OF APPLICAN -:''�?�� PRINT NAME �E?C�E'cMJy (1'e`J G'� � DATE ���-��
APPROVALINSPECTO�IGN —� DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977