P - 35056.
Building
Inspections
763-572-3604
763-502-4977 FAX
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DATE
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 7-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER
NAME: �l A G
CONTRACTOR NAME: (",j��„
SUBMIT A COPY OF ii`-P`
YOUR STATE STATE LICENSE #_
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF �DRESS:�
INSURANCE pHONE (/�J� `
PERMIT TYPE
TYPE OF WORK: I� NEW
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FAMILY ❑ TWO FAMILY
DETAILED DESCRIPTION OF WORK
$�J�REPLACEMENT
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❑ TOWNHOUSE
Permit No: �
Received By:_
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EXP DATE
EXP DATE
'��1 STA � ZIP S Z�
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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) 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 pe 't and wor1 ' ot to start without a permit on site; that the work will be in accordance
with the approved plan in the case of all wor i �d-approya_l-o a�}s ' I
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SIGNATURE OF APPLICANT
. �-y��� `� �rrT NAME� I�.t - - - Y .��`� ,MQ,�I��?�r2 ��i
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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