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P - 48649Building Inspections 763-572-3604 763-502-4977 FAX DATE �v ��✓ ( � SI1'E ADDRESS _�,�„ THIS APPLICANT IS: PROPERTY 0�4'1�IEi2/ TENANT �������� �E�g��I�T'�'�� A������'�'��I� �.��� ��' ������ F.FFECTIVE 7-1-2010 _ YOUR E-MAIL ADDRESS ❑ OWNER �CONTRACTOR Permit No.�G �� �-��' Received By: ��wi��-�'--,'�-� CONTR.�C"I"OR NAME: SUBMIT A COPY OF STATE LICENSE # # 6177i1—PM EXP DATE YOURSTATE LICENSE, BOND AND STATE BOND # 651-365-1340 EJ�T DATE CERTIFICATE OF �Dx�ss: 3670 Dodd Rd. cITY STATE Z1P INSURANCE PHONE a9an� FAX PEIt1VIIT TYPE TYPE OF WORK: �INGLE FAMILY ���� DETAILED DESCRIPTION OF WORK ❑ TWO FAMTLY ❑ TOWNHOUSE C�PLACENJENT FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTTJRES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE $35.50. BATH SINK/f.AV _FLOOR DRAINS SHOWER _ WATER PiPING Bq'IT3TCTg GAS PIPING (NEED CITY LIC) SWIIvII��TG POOL _ WATER SOFTNER ($35) CLOTHES WASHER KITCHEN SIlVK WATER CLOSET _ BACKFLOW PREV. ($1�) DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IItRIGATION — WATER METER _ OTHER THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED I hereby apply for a plumbin; permit and I 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 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 with the approved plan in the case of all which requ' s re ' w and app of lans 3^ ZL_ ( y SIGNATURE OF APPLICANT A ��1 S c�� DATE APPROVAL INSPECTORS SIGNATURE PLEASENOTE:.`SEPARAT TS ARE REQ OR BLTILDING, ELECTRICAI, AND 1VIECHAIJICAL WORK �1�' 0� ��'l���y �3u�ldang Inspeetnons Departme�t 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977 �