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SI'I'L ADURLSS _�L__�
TH1S APPLfCANT [S:
PR�PERi�
OWNEIt1
T�NAN'F
CONTRACTOR
SUI3MCf A COPY OP
YOUI� STAT�
LIC�NSE, BOND AND
CERTIFICATE OF
INSURANC�
PERMIT TYPE
��������
Per�niL hlo.
�������``�T���.� �1.�����!�s.���� � Receivec'�
i
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EF?=�CT[VG i-1-^_O7' �
Y'OUP. !�-��QAIL f�DDRT�SS
�'I�lt,l. ►Q.d� N �'.
❑ OWNEP �SICONTRACTOi:
NAML- l
ADDRLSS:
rxoN�:
STATE LIC�NSE #
tL
� r.
CITI' �^ y� j�► t,�_STATLMI�ZIY��
EXi' DATE
STATG BOND # EXP DATE
ADDRCSS:_ Dd- 1� � ��,,. rcCJo N L CITY ��.Q.t +4 �� STATL r"I�- ZIP ,C �i �
PHONE �� '� S 4 a-� �I g FAX
TYPE OF WORK: I� NEW
FAMILY ❑ TWO PAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
�
�PLACEMENT
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (IND[CATE TOTAL NUMBER.OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER KITCHEN S1NK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY =WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
TIIIS 1S AN APPLICAT[ON POI2 A PCRMIT-NOT VALID UNTIL PROCI3SSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that tl�e work wili be in
conformance with the ordinances and codes of tlle City of Fridley 1nd witl� the Minnesota Construction Codes; that l understand this is
not a permit but only an application for a ermit ancl work is not to start without a permit on site; that the worlc will be in accordance
with the approved plan in the case of all w ich requires review and approval ofplans.
sicNaruR�oF,���LicnNT Cl,�n..:.� n�urv�rrvAMe C�4��s {/Z.�,a n ��aTC 3- k- 1 L
APPROVALINSPECTORSSIGNATUR� �� DAT6
�'�� � PLE,�SE NOTE: SEPARATE��PERNLi� R'�� ��'RE �TIRED ('�R �L'ILDING.,ELECT�R�ICA�L��AND��MEC.HANICA�L WORI�� �
�''�ty ��' ��-ac�l�y
��iic�in� �ns�ee�ions �epa��tnent
6431 University fl.venue T�IE. Fridlev, MN S��k3?
763-��?-3604 -
i� AX: 763-�02-�977