P - 48304Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �7( � / �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTO�L
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFTCATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
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EFFECTIVE 7-1-2010
❑ OWNER
ADDRESS:
ADDRESS
cmr
Permit No.: ��
Received By�/ �'" f
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STATE LiCENSE # 177O-PM EJQ' DATE t ` Ia
STATE BOND # 1-365-1340 � D.a�
aDDxESS: 3670 Dod •�Ty STATE z�
PHONE agan° F�
❑ SINGLE FAMII.Y
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY 0 TOWNHOUSE
�,$EPLACEMENT
FEES ARE BASED ON $10.00 PER FIXT[7RE, EXCEPT WHERE NOTED. FIXTi7RES: (INDICATE TOTAL NUMBER OF EACH BELQW). MINIMUM FEE
$35.50.
BATH SINIC/LAV FLOOR DRAINS SHOWER _ WATER PIPING
� BATHTUB GAS PII'ING (NEED CITY LIC) SWIIvIIvIING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER HITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35) FOR IltRIGATION
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 work will be in
conformance with the ordinances and codes the City Fridley and with the Minnesota Consiruct4on Codes; that I understand this is
not a permit but only an application for a permit d w is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case o work whic view and appro al of plans.
SIGNATURE OF APPLICANT ME DATE v� "�-��
APPROVAL INSPECTORSSIGNAT IX+ __..._ :_.
�.y C'ity of Fridley
$ualding Iaaspectnons Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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