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P - 35062Building Inspections 763-572-3604 763-502-4977 FAX DATE ��` �'l - SITE ADDRESS THIS APPLICANT IS: PROPERTY OWNER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE, BOND AND CERTIFICATE OF INSURANCE PERMIT TYPE PLUMBING RESIDENTIAL APPLICATION CITY OF FRIDLEY EFFECTIVE 7-1-2010 YOUR E-MAIL ADDRESS ❑ OWNER ADDRESS: C1TY STATE LICENSE Permit No.:��� �O Received By: j ! � �- Dat�d• ATE ZIP EXP DATE � �'J � ' STATE BOND # 3�,Q �%N�ZF> EXP DATE �� �' ADDRESS: � g% Z����ji.�i f�� � CITY �j��./ jL/ ,P STAT�ZIP� PHONE 7�.?%y7S� :� — [S J `7 .� FAX � 6 � "'7� 7— � �,5� �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE TYPE OF WORK: � �W � �pLACEMENT . DETAILED DESCRIPTION OF WORK � FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELAW). MINIMUM FEE $35.50. BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35) CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15} _ DLSHWASHER _ LAUNDRY TRAY [�'fER 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 approved plan in the� cas�ef� 11 work which requires review and approval of pl sp. j /' SIGNATURE OF APPLICANT�a'Pw.v�,��J�.�. � �r�% PRINT NAME��r � Iri � . �i1�%/ DATE � / � �'I' °- J � APPROVAL INSPECTORS SI NATURE City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977