P - 35173Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
n•rsux�NCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT[VE 1-1-2011
YOUR E-MAIL ADDRESS I�rC��� �f .
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STATE LICENSE # Q
STATE BOND # %'
ADDRESS: /oZOl�
PHONE /�o,�',
�$,INGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
%�,��N�
J �o �
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❑ TWO FAMILY
G�2EPLACEMENT
CITY_
FAX
❑ TOWNHOUSE
Permit No.:I�J
Received By:1
Date R��e�d� ' �
����
STATE ZIP
EXP DATE c� .� ��
�XP DAT /a/3/ ��
.��S STATE /"�✓ZIP��3
FEES ARE BASED ON $10:00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV1n. MINIMUM FEE
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 [RRIGATION
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 case f a hich requires review and approval of plans,-L_��. /q
APPROVAL INS ECTO S SI A RE,/����� PRINT NAME 1�'(L`�N���� S�r1 DATE /!��� �/
✓
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977