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P - 39992� _ Building Inspections 763-572-3604 763-502-4977 FAX DATE �' I �- SITE ADDRESS i � � THIS APPLICANT IS: PROPERTY OWNER/ TENANT PLUMBING RESIDENTIAL APPLICATION CITY OF FRIDLEY EFFECTNE 7-1-2010 YOUR E-MAII, ADDRESS ❑ OWNER �ONTRACTOR CITY Permit No.: lQ Received By: � . i;. s't �� STA' CONTRACTOR Nn�: Champion Pl�mhina SUBMIT A COPY OF STATE LICENSE # #' B� %%O^PM EXP DATE 12- (( YOUR STATE 65'I -365-1340 EXP DATE _ I Z-� LICENSE, BOND AND STATE BOND �_. —�— CERTIFICATE OF �DRESS: � ' CITY STATE ZIP INSURANCE PHONE ' F� PERMIT TYPE TYPE OF WORK: � a rrsw FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE DETAILED DESCRIPTION OF WORK .�R�PLACEMENT ~ � r� FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXT'URES: (INDICATE TOTAL NUMBER OF EACH BELOV�. NIINIMtJM FEE $35.50. , BATH SINK/LAV _FLOOR DRAINS SHOWER _ WATER PIPING � BATHTUB GAS PIPING (NEED CTTY LIC) SWIIvIlVIING POOL WATER SOFTNER ($35) CLOTF�S WASHER KITCHEN SINK WATER CLOSET _BACKFLOW PREV. ($15) DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IltRIGATION ' WATER METER ' _ OTHER THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII, 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 f Fridley and with the Minnesota Construction Codes; that I understand this is not a permit but only an application for rmit a o is start without a permit on site; that the work will be in accordance with the approved plan in the case of al ' ' v�f plans. _ q SIGNATURE OF APPLICANT NAME �/1�.-S ��, �1�DATE 1 ' ( �--" � � APPROVAL INSPECTORS SIGNATURE `�V City of �ridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977 ) �5�s �