P - 45221Building
Inspections
763-572-3604
763-502-4977 FA�
DATE I [ � �
STTE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
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EFFECTI V E 1-1-201 ]
YOUT. E-MAIL ADDRESS _
( M.0 Y'C, j,/ t l�,L�
O OWNER �„CONTRACTOR
ADDRESS: 1 U i s
PHONE: �� L �
CONTRACTOR NAME: I� � '�
SUBMIT A COPY OF STATE LICENSE #
YOURSTATE
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF ADDRESS:�
INSURANCE �1,�' �
PHONE � �z �'i
PERMTT TYPE
TYPE OF WORK:
�SINGLE FAMILY
/ `
❑ NEW
DETAILED DE5CRIPTION OF WORK
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❑ TWO FAMILY
I�,BEPLACEPvIENT
i
ctTY_�-�r�lv_c
_CITY �{�
_ FAX �
❑ TOWNHOUSE
Permit N
Received By: V
Date Rec'd: � � < <
ATEI�N�(. ZIP:SS��`
EXP DATE
EXP DATE
' STATE ZIP,i � 2.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINKlLAV FLOOR DRAINS SHOWER WATER P1PING
BATHTUB GAS PIPING (NEED CITY LIC) � SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK WATERCLOSET BACKFLOW PREV. ($15)
_ DISHWASHSR `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 informaiion 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 application for a permit and wo 1'c is not to start without a permit on site; that the work will be in accordance
with the approved plan in theG��'e n all Y��� �c�whic r lres review and approva o lan/�':, ./�
SIGNATURE OF APPLICANT ��' �"� � PRINT NAME�/ �' U �yY� � _ DATE � � � ��
APPROVAL INSPECTORS SIGNATURE DATE
" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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