P - 43817Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� O`C/
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
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CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTTFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
Permit No.:` �
RESIDENTIAL APPLICATION Re�ei�ed By:1�± �
CITY OF FRIDLEY ��eg'�,
EFFECTIVE 1-1-2010
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YOUR E-MAIL ADDRESS ! /� �/�lJS� �
S�T _
❑ OWNER
NAME:
ADDRESS: CITY
PHONE:
ATE ZIP
NAME: I� �i��- /
STATE LICENSE # D D�Z TJS�f '' ��'i EXP DATE o� '�� o�O[
STATE BOND #��� �� �� Y EXP DATE � a- �- aor v
ADDRESS: I Y����� P�'✓ � CITY_��1� /VY.14�l� STATE�ZIP_��
PHONE ��A �' v7�g'"' � yy FAX ��b 3^ ��l- y� ��d
�1 SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
. O TWO FAMILY
�REPLACEMENT
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❑ TOWNHQUSE
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FEES ARE BASED ON $10.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUM$ER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER _ WATER PIPING
BATHNB GAS PIPING (NEED C1TY 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 UIdTIL 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 nd work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all wor ich requires review and approval of plans.
SIGNATURE OF APPLICANT ��Z���� j!���''�G+' PRINT NAME �`✓l /jC,ll✓y /'�1��5� `P��ATE �'-���U
�„�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
' FAX: 763-502-4977