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Inspections ��������g„ �ppg����'g'���
763-572-3604 ���� �� ������
763-502-4977 FAX EFFECTIVE7-1-2010
DATE 1 L� \ ^
SITE ADDRESS �
THIS APPLICANT IS:
OWNER/
TENANT
CONTRACTOI2
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
• INSURANCE
YOUR E-MAIL ADDRESS
rS 5 V 1� �r
O OWNER �CONTRACTOR
CITY
Permit No.:
Received By:' �
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STATE LI�ENSE # ' EXP DATE
STATE BOND # EXP DATE
ADDRESS: CITY STATE ZIP,
PHONE � FAX
PERNIITTYPE I�INGLEFAMILY
TYPE OF WORK: I � �
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOVSRIHOUSE
�PLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT VVHERE NOTED. FIXI2TRES: (INDICATE TOTAL NLIIvIBER OF EACH BELOVI�. IvIINIMtTM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS P1PING (NEED CITY LIC) SR��IG POOL WATER SOFTNER ($35)
CLOTE�S WASHER KTfCHEN 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 UNTII, PROCESSED
I hereby apply for a plumbing permit and I acknowled'ge that t ormation above is complete and accurate; that the work will be in
conformance with the ordinances and cod City of Fri e and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a perm' an rk ' to s.art without a permit on site; that the work will be in accordance
with the approved plan in the case of all wor i% 1 of plans.
SiGNATURE OF APPLICANT 0�2� _ � Lu� ��� ��JyLl�DATE� Z�`� ''� �
- // -��City of &'ridley
�'ug nspections Department
6431 University Avenue NE, Fridley, MN 55432
7b3-572-3604
FAX: 763-502-4977
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