P - 35778Building
Inspections
763-572-3604
763-502-4977 FAX
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-i-2010
DATE `- 1
SITE ADDRESS r ►
THIS APPLICANT IS. ❑ OWNER
PROPERTY NAME:���
OWNER/ A��RESS: oZ�
TENANT ,�y
PHONE: 7�.l�
YOUR E-MAIL ADDRESS
CITY
Permit No.: �
Received By:
Date��:�
ATE�I�ZIP,
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # 31-1815874 EXP DATE
YOURSTATE
LICENSE, BOND AND STATE BOND i! EXP DATE
CERTiFICATE OF ADDRESS: w'A �s n.....:�.. �+:....1�TY STATE ZIP
INSURANCE PHONE � ...■ �.�w.��r ��'. �.JfT'� �'IY�'J' ' �i Ov�
PERMIT TYPE
TYPE OF WORK:
'�INGLE FAMILY
O NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY O TOWNHOUSE
�REPLACEMENT
FEES ARE BASED ON SI0.00 PER FIXTURE, EXCEPT WHERE NQTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB J GAS PIPING (NEED CITY 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 APPUCATION 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 c, wo � h' rec� 'res review and appr va1 of plans. j� [ ��—
SIGNATURE OF APPLICANT PRINT NAME ✓Yi 1 C..__ �LQl�il(' DATE � � ZU
APPROVAL INSPECTORS SIGNANRE c . " . �_ � � � �
_�/ City of Fridley
Building I�spections Department
6431 University Avenue NE, Fridley, 1b4N 55432
763-572-3604
FAX: 763•502-4977
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