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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ( ' d
SITE ADDRESS _
THIS APPLICANT IS
PROPEY2TY
OWNER/
TENANT
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YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
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PHONE: '.Nn ` • S � �
Permit N
Received By:
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CONTY�C�'OR NAME:
SUBMIT A COPY OF STATE LICENSE # ampion U111 111g
YOUR STATE EXP DATE
LICENSE, BOND AND STATE BOND tl ExP DATE
CERTIFICATE OF p,�DRESS: �R7f1 �'lnrlrl Rr( i.ITY STATE ZIF'
INSURANCE
PHONE Faaan MN SS12� F�
PERNdIT TYPE
TYPE OF WORK:
�) SINGLE FAMII,Y
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
DETAILED DESCRIPTION OF WORK _��.��/ ��,��( rP.�Q�,G�,C�I.�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�. 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. ($1�)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
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THIS I5 AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbing permit and acknowledge that the information above is complete and accurate; that the work wili be in
conformance with the ordinances and codes the Ci f Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe it work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case a r c ' w d appr qval of plans.
SIGNATURE OF APPLICANT ANIE� )�,�,y,n,e �C� /YjP,pe.✓ DATE J I' o�'g� � I
APPROVAL INSPECTORS SIGNAT . /1 -7'T—
City of Fridley
�ugldang �nspections D�partment
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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