P - 43623Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I i� '
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�S���N�'�A�., ����IC'�'�'���T
CI'T�' OF ������'
F.FFF.CTTVE 7-1-2010
YOUR E-MAIL ADDRESS
SITE ADDRESS f7'� l�. (� V"`�1 1 !i/ \ I V�`
THIS APPLICANT IS: � OWNER �CONTRACTOR
PROPERTY NAME:�)
OWNER/ anDx�ss:
TENANT __ ,
CIT'Y
Permit No.:
Received. By: l � ��'
����� � � ����
CONTRACTOR N�: �•
SUBMIT A COPY OF 'b����ng ^�
YOUR STATE STATE LICENSE!! # C�177O-PM EXP DATE CO� '�f ���
LICENSE, BOND AND STATE BOND # 651-365-1340 EXP DATE
CERTIFICATE OF ,�,DDx�ss: 3670 Dodd Rd.��-y STATE ZIP
INSLTRANCE PHONE a9an' FAX
PERMIT TYPE
TYPE OF WORK: � � �
FAMII.Y ❑ TWO FAMILY
DETAILED DESCRIPTION OF WORK
�REPLACEMENT
❑ TOWNHOUSE
CtiCQ �wr�.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTC7RES: (INDICATE TOTAL NUMBER OF EACH BELOV�. MII�IIv1UM FEE
$35.50.
BATH SIl1K/LAV fZOOR DRAINS SHOWER WATER PIPING
BATHTU$ GAS PII'ING (NEED CITY LIC) SV«�IIv1II1G POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHrN SINK WATER CLOSET _BACKFLOW PREV. ($15)
DISHWASHER LALJNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
` WATER METER _ OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for aplumbing permit and I acknowled'ge 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 an work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case '/.� ,�d apprqval o�%—_-���
SIGNATURE OF APPLICANT �� AMEy� � S IYI DATE �O'� ��
City of �'ridley
Build'ang Inspections ]Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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