P - 40705Building
Inspections
763-572-3604
763-502-4977 FAX
DATE -j � 1 1 '
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
YOUR E-MA:
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❑ OWNER �f'9CONTRACTOR
ADDRESS: � G A� CITY,
rxorrE: � ���2� '� ' 2. L-
STATE LICENSE #
Permit No.:��� ��i'
Received By✓� �t'�I`
Da���d��� 2+ 7�
EXP DATE
STATE BOND # � V � � � "-� ��� EXP DATE
ADDRESS: ��7f1�r1�R�. CITY STATE ZIP.
rxorrE ���n MN 55123 F�
TYPE OF WORK: I � �'
FAMII.Y ❑ TWO FAMILY ❑ TOWNIiOUSE
DETAILED DESCRIPTION OF WORK
�1 REPLACEMENT
�;5
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHE1tE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). NIINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER _ WATER PIPING
BATHTLTB GAS PIPING (NEED CITY LIC) SWII��NIING POOL WATER SOFTNER ($35)
CLOTHES WASHER HITCHEN SINK ^ WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WATER METEIZ _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 code the City f Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for perm �nd rk is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case of V ���proval of plans. - 1� � DATE !"I 9� �/
SIGNATURE OF APPLICANT � �"'e I-
APPROVAL INSPECTORS SIGNA _ ,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604
FAX: 763-502-4977
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