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P - 44212Puilding P�,IJl�/I�II�� Inspectians �.ESID�loT�IAL r���LICA�'IOI� 763-572-3604 �ITY ��+ �����,�+ � 763-502-4977 FAX EFFECTIVE 1-I-2010 DATE �_ SITE ADDRESS _ THIS APPLICANT IS: PROPERTY OWNER/ TENANT � U � � ❑ OWNER c NAME: ADDRESS:_� PHONE: � n� � . CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE, BOND AND CERTIFICATE OF INSURANCE PERMIT TYPE TYPE OF WORK: YOUR E-MAIL ADDRESS _ ., _. ��.. i ,.. !,� CITY Permit No. � - -. : �� �' s �,� : � STATE ZIP, STATE LICENSE # � �l / /U�F'M EXP DATE STATE BOND # EXP DATE ADDRESS: Fanan 1►�A1 �����ITZ' STATE ZIP PHONE FAX �SINGLE FAMILY ❑ NEW DETAILED DESCRIPTION OF WORK ❑ TWO FAMILY ❑ TOWNHOUSE C�.EPLACEMENT FEES ARE BA3ED ON $10.00 PER FIXNRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE $35.50. BATH SINK/LAV �FLOOR DRAINS SHOWER _ WATER PIPING —gp�'I'Ug GAS PIPING (NEED CITY LIC) SWiMMING POOL _ WATER 50FTTIER ($35) CLOTHES WASHER KITCHEN SINK WATER CLOSET _ BACKFLOW PREV. ($IS) _ DISHWASHER _ 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 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 application 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 case o� l work�v�iich requires review and approval of plans. SIGNATURE OF APPLICANT � ��-�� '""�""�� `PRINT NAMES `� INYi� C� tl'�I.l"�R/I DATE �� � v City of Fridley Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 ' FAX: 763-502-4977 `�r��� -� Y l�