P - 60372�uilding
Inspections
763-572-3604
763-502-4977 FAX
DATE `�� — � �
SITE ADDRESS
THIS APPLICANT IS:
PROPEi2TY
OWNER/
TENANT
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YOUR E—MAII, ADDRESS
❑ OWNER �CONTRACTOR
Permit N
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corrTx�c�o�a NAI,,�: Champion Plumbin�
SUBMIT A COPY OF STATE LICENSE # # G� T%O—PM EXP DATE �� "�' �/�_
YOURSTATE
LICENSE, BOND AND STATE BOND !/ 651-365-13 �,� DATE
CERTIFICATE OF �DRESS: � � CTTY STATE ZIP
INSURANCE PHONE ' F�
PERiVIIT TYPE
TYPE OF WORK:
�SINGLE FAMII.Y
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FA'TURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMtJM FEE
$35.50.
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CTTY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER � KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($1�)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER _ OTHER
—;���, —
THIS IS AN APPLICATION FOR A PERMIT—NOT VALID LTNTII. 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 pek �it and ork is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case o 1 work wl�° e eview and appro al of plans. /� /�
SIGIQATURE OF APPLICAI�TT �QAME� �DATE `7 ' % /�
APPROVAL INSPECTORS SIGNA
.;;: PLEASE NOTE: 'SEPA ' PERMI ; Q D FOR BUIi:;DING, ELECTRICAL'AND MECHANICAL WORK _;;'
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�ugiding Insp�ctgons Depar�m�nt
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 76�-502-4977
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