P - 42253Puilding
Inspections
763-572-3604
763-502-4977 FAX
DATE Ul 0
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
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Permit No.9�`C1 �liZ ,
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EFFECTIVE 1-1-2010 _ _
E-MAIL ADDRESS
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❑ OWNER
NAME: f I U r.JU _�
ADDRESS: -7
PHONE: , � D [ � �
STATE ZIP,
CONTRACTOR NAME: C`�amninn PIlJt71b111q
SUBMIT A COPY OF STATE LICENSE # # B� %%O'PM EXP DATE
YOUR STATE
LICENSE, BOND AND STATE BOND # C"irJ�I'�E�7�J-1340 EXP DATE
CERTIFICATE OF ADDRESS: � CITY STATE ZIP
INSURANCE pHONE ' FAX
PERMIT TYPE
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRiPTION OF WORK
�REPLACEMENT
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 C1TY LIC) SWiMMING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET _ 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 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 a roved lan in the case of all work wh�ch r�equires review and approval of plans.
PP P ,.� .ri'� _ i . _ _. � !! ,.n - - - -
SIGNANRE OF APPLICANT
NAME
City of Fridley
Buildia�g Iaspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
` FAX: 763-502-4977
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