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Puilding p�,�.J����
Inspections ��������� ����,�������
763-572-3604 ���,� �� ������
763-502-4977 FAX EFFECTIVE7-1-2010
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SITE ADDRESS ��/L () L C UU
THIS APPLICANT IS: ❑ OWNER
PROPERTY NAME:
TENN�T ADDRESS: , n
YOUR E-MAII, ADDRESS
Permit No.�OI
Received B,
Date,Re�:s�:
--5�3
CONTRt�CTOR NqME: l+h�mninn DL �mi�i .. _ _— -
SUBMIT A COPY OF STATE LICENSE # 177(t�PM EXP DATE
YOUR STATE �-�-
LICENSE, BOND AND STATE BOND # 651-365�� `a�O EXP DATE
CERTIFTCATE OF ,c„vDRESS: a3GTO DOCiCI RC�',ITY STATE ZIP
INSURANCE PHONE ��� 2�AX
_
PERMIT TYPE �INGLE FAMII:Y ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: ❑ NEW i�REPLACEMENT
DETAILED DESCRIPTION OF WORK G, �,,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT VVHERE NOTED. FIXT'URES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MINIIv1UTvI FEE
$35.50. ;:
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHNB GAS PIPING (NEED CTTY LIC) ' SWIIviI��IG POOL WATER SOFINER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LALTNDRY TRAY �WATER HEATER ($35) FOR ]RRIGATION
WATER METER OTF�R
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbin� permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and co �f the of Fridley and with the Minnesota Consisuction Codes; that I understatid this is
nat a permit but only an applicatio for a pe 't c is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c ' and appro al of plans.
SIGNATLTRE OF APPLICANT PRINT NAME�� w�..i .� (I���.Q� DATE I a�I Cl'II
APPROVAL INSPECTORS SIGN
>' Pi.F.ASRNnTF.•"fiFP ATF P. R.nTTTRRI� FCIR RT7TT:l�TNC'T_ ET.F.C'.TRTCAL'AND:IVIECHANICAL_WORK ..
Cl�' Of ��'lf���y
uilding Inspections Departflnent
1 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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