P - 44938Building
Inspections
763-572-3 604
763-502-4977 FAX
DATE ` IO
S1TE ADDRESS��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CQNTRACTOR
SUBNIIT A GOPY OF
YovR sTA�
LICENSE, BOND AND
CERTTFICATE OF
LVSURANCE
u
PLUMBING
RESIDENTIAL APPLICATION
CITY UF FRIDLE�
YOUR E-MAIL ADDRESS
Q OWNER �G9�i�'RACTOR
� �, ;
Permit No.:
Received By:
ATE Zli'
STATE LICENSfi # � � EXP DATE
STATE BOND rf EXP DATE
ADDRESS; CITY STATB ZIP
PHQNE
PERMIT TYPE aLE FAMILY
TYPE OF WORK: ❑ N�
DETAILED DE3CRIPTION OF W�RK
❑ TWO FAMILY
�,FiPL-ACEMENT
EAX
❑ TOWNFiOUSE
FEES ARE BASED ON S1U.00 PER FDC!'URE, EXCEPT WfiERE NpTED. F7XTURE9: (INDICATE TOTAL NUMBER OP EACIi BBL01R�. MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WA7BIt PIPQVO
BATHTUB GAS PIPING (NEED CITY LIC) � SWIMMAVG POOL r WATER SOF'TNER (x3�
CLOTHES WASHER KITCHEN SINK WATER GIASET BACKFLOW PREV. ($1�
_ DISFiWASHER _ LALNDRY TRAY \VATER HEATER (S3� FOR IRRIGATION
�WATEA METER {//�'��Cs S _ 07�R
TH1S IS .'�N APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing pamut and I acknowledge that the information above is complate and accurate; that the work will be in
conforntance with the ordinances and cades of the City of Fridley and with the Minnasota Constntction Codes; that I understand this is
not a perxnit but only an application for a ' and wo c is not to st�rt without s permit on site; that the worlt will be in accordance
with the approved plan in the case re revievv and approv�al a,f� lans. /� _/��� �.�r
SIGNATURE OF APPLICANT � , . � pRINT AME %�E'��[,�/ / Jr���G¢CX�TE f� ~�3/ �
�ity of Fridley
Building Iaspections Depsr ment
6431 University Aveaue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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