P - 42336�uilding
�nspecti�ns
763-572-3604
763-502-4977 FAX
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SITE ADDRESS ��
THIS APPLICANT IS:
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YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
Permit No.:
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PROPERTY NAME: -�. 1 i �
OWNER/ ADDRESS: 0. [ CITY I STATE�ZIP���
T�NANT pHONE: �� �'' J �� � b " �
CON`I'F2�.CTOR NAME:
SU$MIT A COPY OF STATE LICENSE # # Fi177C1 PA,A EXP DATE
YOUR STATE
LICENSE, BOND AND sT.a� sorrD # 651-365-1340 ExP DATE
CERTIFICATE OF ADDx�ss: 3670 Dodd Rd. CITY STATE ZIP
INSURANCE pHONE gan' FAX
PEflt1VYIT TYPE
TYPE OF WORK:
� SINGLE FAMILY
❑ NEW
DETAlLED DESCRIPTION OF WORK
❑ TWO FAMILY
i�EPLACEMENT
❑ TOWNHOUSE
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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
BATHTUB GAS PIPING (NEED CITY LIC) SW[MMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($IS)
DISHWASHER _ LAUNDRY TRAY �WATER HEATEA ($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 compiete 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 withoat a permit on site; that the work will be in accordance
with the approved plan in the case of all work which requires review and approval of plans.
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SIGNANRE OF APPLICANT � ' `�` -�.��t�----
�ity Of �'�-ia��y
�uilding �nspe�ti�a�s Dep�rtment
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977 ` f ����
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