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�nspectior�s �,�������� ����,������1�T
763-�72-3604 _ ���� �� �����+ �
763-�02-4977 Ff� EFrECTiv��-�-ao�o
DATE '
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTI' A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMTT TYPE
�rYrE oF woxx:
YOUR E-MAIL ADDRESS
❑ OWNER ❑CONTRACTOR
NAME:
ADDRESS: C C' .S � CITY�
PHONE: �P�� � y .� Y�U
NAME: f v't/ � G/���4 �fi yn yl � S
STATE LICENSE #
STATE BOND #
ADDRESS: CITY
PHONE FAX _
INGLE FAMILY
❑ NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
l� �_ ,o c�rl a
�
❑ TOWNHOUSE
Fermit No.:
Received By:
Date Ree'd:
EXP DATE
EXP DATE
�ir c
ATE_ '�9ZIP
ATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NiJMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMI��IING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) �GA'I'ION
_ WATER METER _ HER
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 of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicati n for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the f all work,�+hich requires review and appro�va/] of la�+ _/ /
SIGNATURE OF APPLICANT PRINTNAME/!�/C� ( C���— DATE
APPROVAL INSPECTORS SIG RE __ _
City of Fa�idley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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