P - 44231Building PLUMBING pe�it No.: �� ��� ��t��
Inspections RESIDENTIAL APPLICATION Received By: (� �
763-572-3604 CITY OF FRIDLEY Date Rec'dN:
763-502-4977 FAX EFFECTNE 7-1-2010 �1 � F�► � _
DATE b �f'lU
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
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❑ OWNER [�ONTRACTOR
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I.Uadd S'a�
PHONE:
NAME: �LtV�l���i' � �'7-C�evm{.tGV►
STATE LICENSE # �` a3 6� P�'"`
STATE BOND # _ �%� � g {� Ig�
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PHONE G'`�
SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�REPLACEMENT
�V �C� I2'f STATE ZIP
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EXP DATE C
EXPDATE �a-3����
Bf S N'� �� STATE �� ZIP S�I Z
FAX
❑ TOWNHOUSE
�S P�' l.Ua f�� I� e
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELAW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOF'TNER (S35)
CLOTHES WASHER KITCHEN SINK WATER CLASET BACKFLOW PREV. ($15)
_ 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 wili 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 wiil be in accordance
with the approved plan in t�� of 1��6� h requires review and approyal of lans.p uv 1ck� ✓�'T g' {��(j
SIGNATURE OF APPLICANT � PRINT NAME CiL' � C7 ` DATE
APPROVAL INSPECTORS SIGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977