P - 47948Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �~. � I�
SITE ADDRESS IC �
7'HIS APPLICANT IS:
PROPER
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
YOUR E-MAIL ADDRESS
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❑ OWNER IaCONTRACTOR
TY NAME:
OWNER/ ADDRESS: CITY
TENANT
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
1NSURANCE
NAME: I,/u o�
STATE LICENSE #
STATE BOND #
.
�a
PHONE(��2— Sj/�--,���� FAX
PERMIT TYPE I �SINGLE FAMILY
TYPE OF WORK: �� NEw
AILED DESCRIPTnION OF WORK
;�,lv4c�i�r � ICL3. -�c'7�:^c
O TWO FAMILY
� REPLACEMENT
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❑ TOWNHOUSE
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Permit No.: � ���
Received By: � I�
Da�'d� � �
P l� 1���1 �; � r? ff�, t.���`l
STATE ZiP
EXPDATE�'�� ,J�— ��
EXPDATE I�r�— ��—�l
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
�.50.
BATH SINK/LAV FLOOR DRAINS SHOWER L WATER PIPING
_ BATHTUB � GAS PIPING (NEED GITY LIC) S WIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER � KITCHEN SINK o� WATER CLOSET BACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
THIS 1S AN APPLICATION FOR A PERMIT-NOT VAUD UNTIL PROCESSED
I hereby apply for a plumbing permit and 1 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 th'ts 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 e Qf� Il which requires review and appro I of plans. ^�
SIGNATURE OF APPLICANT �-''�'� `�/l+- ���- PRINT NAME �d �� � n I,�Ltn L�I4 �� 1 �� DATE � "� / '" ��
APPROVALINSPECTORSSIGNATURE 1lATF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977