P - 35772Building PLUMBING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFEC�nvE �-�-zo>>
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SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTTFICATE OF
INSURANCE
PERMIT TYPE
YOUR E-MAIL ADDRESS
5 c.... r: t..� �.r . '� , � •
❑ OWNER �CONTRACTOR
ADDRESS: CITY
PHONE:
NAME:_in/`-l.. .1�!`u�/�.^���.r �'e.�_�
STATE LICENSE #
STATE BOND #
ADDRESS: ���C� �4,I�1 ��i�n� � � CITY L.c�e.'
PHONE R S 2—�� S�- Z � 3 � FAX
� SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW
�REPLACEMENT
DETAILED DESCRIPTION OF WORK _�� , .�
iv�. Ta.�..1� c�...e� �s �•:, s.n �- r..�
Permit No.:
Received By:�!��
i
EXP DATE
�1EX_P DATE
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ATE ZIP.
'ATE�ZIP S3 6
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXNRES: (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)
1 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 acknowl ge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of th ty of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a p ' nd work is not to start without a permit on site; that the work will be in ac ordance
with the approved plan in the c s o 1l r 'ch requires review and approv,�� f p ns. c/
SIGNATURE OF APPLICANT PRINT NAME �/ �'G� �- L ��(� DATE cl / t
APPROVALINSPECTORSSIG ATURE _ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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