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SI'fcADDR1�S�'
THIS APPLIG�NT IS
PROPiRi' �'
OWNER/
'd'�NE3N'F
CONTF.A�TOR
SUBMI'I' A COPY O�
YOUR STATG
LIC�NSE. BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
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❑ OWNEh �CONTI:AC"1'OR
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I�ec�ived B�•: ��
NAN�F U r�t L AICJI. b
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STATL LICGNSE #
EXP DATE
STAT� I30ND # EXP DATG
ADDRESS:$e�.�j0 I I�.-t-� eJF• N.� CITY E12lpt� STATL M'� ZIP S���l-
PHONE %�� � Z sy-- �� 9� FAX
�INGLG FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOLJSE
^�K�PLACEMENT
DETAILED DESCRIPTION OF WORK ,ns�q�L___����s--tt,.•••"� w'��w �t t�C �-
1
FEES ARE BASED ON $1 Q00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER.OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER
BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL
CLOTHES WASHER KITCHEN SINK WATER CLOSET
_ DISHWASHER _ LAUNDRY TRAY �WATER HEATER ($35)
_ WATER METER
'PHIS IS AN APPLICATION FOR A PLRMIT-NOT VALID UNTIL PROCGSSED
WATER PIPING
WATER SOFTNER ($35)
BACKFLOW PREV. ($15)
FOR IRRiGATION
_ OTHER
I hereby apply for a plumbing permit and I acl:nowledge that the information above is complete and accurate; that the work will be in
conformance with the ordivances and codes of the Ciry of Fridley and with the Minnesota Construction Codes; that 1 undeistand this is
not a permit but only an application for a permit a�1d wor]< is ❑ot to srart without a permit on site; that the worl: will be in accordance
with the approved plan in the ease of all worlc��v hieh rec�uires review and approy �11� of plans.
slcNaT�JRLOFai>r�LicnN�r C��.,:-e rL�,o,o rr.tN�rNnMe [Y'l�n.n,e �-�-�° �nT� 3•d�-(2
APPROVAL INSPEC'd'ORS SIGNELTLIRE � -�- -� DATL
` PLE.�ISE NOTE: SEPAR.ATE PERNt;fTS ARE REQLJIRED F(�R BUILDING. ELECTRICAL AND �[ECHANICAC WORK
��fiv ��' ��-�Cdl�g�
��iic�in� 1nsa�e��ions �e�a�*me��
b431 'Jnive.•sit�� Avenue �IC. �ridle��, ViN ��432
763-�7?-3604
Fl-� :: 763-�02-�4�77