P - 44212Puilding P�,IJl�/I�II��
Inspectians �.ESID�loT�IAL r���LICA�'IOI�
763-572-3604 �ITY ��+ �����,�+ �
763-502-4977 FAX EFFECTIVE 1-I-2010
DATE �_
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
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� �
❑ OWNER
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NAME:
ADDRESS:_�
PHONE: � n� � .
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
_ ., _. ��.. i ,.. !,�
CITY
Permit No.
� - -. : ��
�' s �,� : �
STATE ZIP,
STATE LICENSE # � �l / /U�F'M EXP DATE
STATE BOND # EXP DATE
ADDRESS: Fanan 1►�A1 �����ITZ' STATE ZIP
PHONE FAX
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
C�.EPLACEMENT
FEES ARE BA3ED ON $10.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV �FLOOR DRAINS SHOWER _ WATER PIPING
—gp�'I'Ug GAS PIPING (NEED CITY LIC) SWiMMING POOL _ WATER 50FTTIER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($IS)
_ 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 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 o� l work�v�iich requires review and approval of plans.
SIGNATURE OF APPLICANT � ��-�� '""�""�� `PRINT NAMES `� INYi� C� tl'�I.l"�R/I DATE �� � v
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
' FAX: 763-502-4977
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