P - 48060Building
Inspections
763-572-3604
763-502-4977 FAX
DATE °� - r-f;�
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
ADDRES
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
rrt,�vr�c,c�
❑ OWNER P�CONTRACTOR
�°
CITY
Permit No.:
Received By:
-�. � "'
NAME: VIICl111�.7�v�� r�uF��an�.b
STATE LICENSE # # EXP DATE
STATE BOND # EXP DATE
ADDRESS: Cr�..er� �AAI F�iS�Y STATE ZIP
PHONE � FAX
�I SINGLE FAMILY
❑ NEW
❑ TWO FAMILY
f�REPLACEMENT
❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK ���G_�i-P/� �r'�t'C-�-"�'� ��;G-�"1 ��✓t/� '�'
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WI-IERE NOTED. FIXTURES: (INDICATE 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 SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ 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 o City of Fri,�ey and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit a d war ;rs not to start without a permit on site; that the work will be in accordance
with the approved plan in the case o work whic view and appr4�val of plans. tn` � ��� //
SIGNA'I"URE OF APPLICANT ' ME �)� � yy�l �'a t►�,��'Ci DATE
APPROVAL INSPECTORS SIGNAT .
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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