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763-572-3604 c�i� oF• ���i��+ y
763-502-4977 FAX EFFECTNE7-1-2010
DATE 2 2 r�
SITE ADDRESS J
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
Permi� Na
Received B��:
YOUR E-MAIL ADDRESS
l,� � L � �
❑ OWNER CONTRACTOR
NAME: {'�
ADDRESS: � C� CITY STAT ZIP.
PHONE: ���l���,�
NAME: K.IWI (/�/ I:UI
STATE LICENSE # EXP DATE
STATE BOND # EXP DATE
ADDRESS:���Ir��I�1� � �� �7�I CITY STATE ZI]
PHONE ��P ��+.��`GCI FAX � �'- �S� Z L �
Y1 SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
l�J
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�, MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMNIING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN 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 UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the wark will be in
conformance with the ardinances 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 permit d work is not to rt without a permit on s' ; that the work will be in accordance
with the approved plan in the e •k w•h r 'res rev'e d appr 1 la is.
SIGNATURE OF APPLICANT �� NT NAM � �t�/" �L DATE ��
APPROVAL INSPECTORS SIGNATURE LL %�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977