P - 44994Building
Inspections
763-572-3604
763-502-4977 FAX
DATE '"I�" U`
SITE ADDRESS �
THIS APPLICA3�IT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
E-MAIL ADDRESS
❑ OWNER J �ONTRACTOR
CITY
STATE LICENSE #
Permit N
Received By: ►'
Dat����d � P {� � 1
EXP DATE
A���z 1
STATE BOND # ��i _�_i 4A �1 EXP DATE
ADDRESS: �B%� i7�fl RC�_ CTTX STATE 2IP
pxorrs_ Eagan, MN 55123 F.ax
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�. MINIMUM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIl'ING
BATHTUB GAS PIPING (NEED CTI'I' LIC) SWIIvIIvIING POOL WATER SOFTNER ($35)
CLO'Tf�S WASHER � KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IltRIGATION
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 wark is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case�,0 f all work w ch re uires review and approval of plans ��B )�
SIGNATURE OF APPLICANT JI�__ _� i�� PRINT NAME �.1.i1'leS �� l`�wLI �� � DATE Y'z �-� I
ADDD/1[/Ai 11�TCDL'!`Tl1DC Ci!_AT�M �� �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
1+�L�48y
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