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DATE � � II
SITE ADDRESS "'
THIS APPLICANT [S
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERNIIT TYPE
�rYrE oF woRx:
E-MAIL ADDRESS
❑ OWNER
NAME:�('; J ��I{�ii
ADDRESS: �0�� �,G� � CITY
PHONE: � 3 - �"���
NAME: I�I UW
STATE LICENSE #_
STATE BOND #
ADDRESS: �D
PHONE ��-
�SINGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
l�@EPLACEMENT
,. ._ �
FAX
❑ TOWNHOUSE
� - • ,'1 �' � 1 °��/y�
I
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�, �ie-�'. � � ��� II
A
EXP DATE
EXP DATE
STATE ZIP ,�v �-
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 _FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFINER ($35)
CLOTHES WASHER KTl'CHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
_ W ATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 perm' d wor � is not to start without a permit on site; that the work will be in accordance
with the approved plan in the/� e of 11 w whic r � es review and approva o lans '//
SIGNATURE OF APPLICANT '/ �- � PRINT NAME�! � � f��j DATE � 7 C
APPROVAL INSPECTORS SIGNATURE /�I �� DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977