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TIIiS APPLI��;NT IS- 0 UWNCR �,OPJTRACTOi�
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YOUR STATL
I,ICENSL, 130ND AND
CERTIPICATE 01=
INSURANCE
PERMIT TYPE
TYPE OF WORK:
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,anDr.LSS �v�l C� C.XX�K ,�ctT��
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STATL LIC�NSG R
GXP DAT�
ATl� ZIP.�+�
STATE DOND # LXP DATL
ADDR�SS: � a/ D :nQ r n 3% CITY F�' d� STATL�ZIP a""
r�ioNE �(0 3— 75�i' oZ(`�� F�x�7G3— S�— a9'p8`
f'J SINGL� PAMILY
❑ N�W
DETAILED DESCRIPTION OF WORK
❑ TWO PAMILY ❑ TOWNHOUSL
C�•REPLACLMENT
FEES ARE BASED ON $] 0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER,OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS SHOWER WATERPIPTNG
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACICFLOW PREV. ($15)
DISHWASHER _ LAUNDRY TRAY �WATLR HEATER ($35) FOR IRRIGATION
— WATER METLR OTHER
.71CI.tG JLLl W11Q1,YJ� .�.: .", w.,.. .�....v.... ., .... , �... , , ����
(MINIMUM $4Q Od) Total = $ �d . 6 �
THIS 1S AN APPLICATION PORA PEIZMIT-NOT VALID UNTIL PROCESSLD
i hereby apply for a pl�imbing pernlit arlci ( ticicnowled�e tl�at the information above is complete and �iccw•�te; that t�l1e worl< will be in
confonnance �-vith i�he ordinances and coc{es of the Ciry of Pcidley and with Che Minnesota Coustruction Codes; that I undersiand Yhis is
not a permit bur on �in applicatioil � r a ��en iC aiicl worl: is not to �tart witl�outi a pemlif on site; that tl�e worlc will be in aecorciance
with t�he approved pl u i� the case of all o� �vhicl� reqL�ires review and ap��roval of plaus.
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