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P - 42104Building Inspections 763-572-3604 763-502-4977 FAX DATE� VI SITE ADDRESS � THIS APPLICANT IS: PLUMBING RESIDENTIAL APPLICATION CITY OF FRIDLEY EFFECTIVE 1-1-Z011 ❑ OWNER YOUR E-MAIL ADDRESS PROPERTY NAME: � (�G OWNER/ ADDRESS: �" �I.� CITY TENANT pHONE: �f � J' /��' 7�( Z� q CONTRACTOR NAME: fL� v�t� SUBMIT A COPY OF STATE LICENSE # YOUR STATE LICENSE, BOND AND STATE BOND # CERTIFICATE OF ADDRESS:� INSURANCE pHONE �12 ;/ ' PERMI'T TYPE �rYrE oF woxx: �SINGLE FAMILY ❑ NEW DETAILED DESCRIPTION OF WORK ❑ TWO FAMILY �.�EPLACEMENT �- � FAx _�� ❑ TOWNHOUSE Permit N Received By: �V1Vf Da,��?aMA1� 2 11 EXP DATE EXP DATE '1 STATE�_ZIP � 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) SWIMIvIING POOL WATER SOFTNER ($35) CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. (S15) _ DISHWASHER _ LAUNDRY TRAY zWATER HEATER ($35) FOR IRRIGATION _ WATER METER _ OTF�R THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED I hereby apply for a plumbing permit a conformance with the ordinances and c d not a permit but only an application for a with the approved plan in tl� s� all � SIGNATURE OF APPLICANT !i APPROVAL INSPECTORS SIGNATURE �dge that the information above is complete and accurate; that the work will be in `i�`y of Fridley and with the Minnesota Construction Codes; that I understand this is � work is not to start without a permit on site; that the work will be in accordan requires review and approv��-1 of pl PRINT NAME �E[ /,�- �f �-�y DATE � �.✓1 DATE �'��� City of Fridley � Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977