P - 46279Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
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❑ OWNEIt
YOUR £-MAIL ADDRESS � M
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NAME: �1/'�(�1P�j� �J (
STATE LICENSE # 7�
STATE BOND #
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DETAILED DESCRIPTION OF WORK
� TWO FAMILY
❑ REPLACEMENT
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FAX
Permit No.:' (
Received By:
Date R���
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EXP DATE %f� ^•
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35 0,
BATH SINKlLAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPMG (NEED CITY L1C) SWIMMING POOL WATER SOFTTIER ($35)
CLOTHES WASHER. KITCHEN SINK �WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) � FOR [RRIGATION
WATER METER OTHER
SHIS IS AN APPLICAT]ON FOR A PBRMIT-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 per ' d work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the all ork ' requires review and appro} �] of plan . /
SIGNATURE OF APPLICANT PRINT NAME V1`� �,��`�T'DATE��'�U— � i
APPROVALINSPECTORSSIGNATURE , DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, �ridley, MN 55432
763-572-3604
FAX: 763-502-4977
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