P - 42335�uilding
�I2SpECt1�riS
763-572-3604
763-502-4977 �AX
DATE / '"�=�_
SITE ADDRESS _
TFiIS APPLICANT IS:
PROP�RTY
OWNER/
'Y'ENANT
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MAIL ADDRESS
❑ OWNER �OCONTRACTOR
NAME: L i 1- �vv
ADDRESS: G CITY
PHONE: � L� � ✓ O � '^
Permit No.:
Received
STATE ZIP
CON'T�CTOR NAME:
SUBMIT A COPY dF STATE LICENSE # # 61770-PM EXP DATE
YOUR STATE
LICENSE, BOND AND STATE BOND # ���'"���"� �'40 EXP DATE
CERTIFICATE OF ADDRESS: � p� �' CITY STATE ZIP
INSURANCE pHONF, ' FAX
PEFtNYIT TY�'E �INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW �� �PLACEMENT
DETAII..ED DESCRIPTION OF WORK � ___��! _�� '� %�� ( .( ��o:-
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS _ SHOWER _ WATER PIPING
—gp��g GAS PIPING (NEED CITY LIC) SWIMMING POOL _ WATER SOFTTIER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
� DISHWASHER _ LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
W ATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowladge 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
w'rth the approved plan in the case of all,,work �hich requires review and approval of plans.
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SIGNATURE OF APPLICANT � � w°°���� '-••° "'"°p�NT NAMES1��a ++� V: DATE
City of �'ridley
�uildi�g �nsp�ctio�s Dep�rtr�e�at
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
` FAX: 763-502-4977
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