P - 42201Building
Inspections
763-572-3604
DATE
sr� a�.Dn�ss
THIS APPLICANT IS:
PRUPERTY
OWNER/
TENANT
SUBMIT A CpPY OF
YOUR STATE
LICENSE WITH ,
APPLICATION
PERMIT TYPE
TYPE OF WORK:
)
PLUMBING
RESIiDENTIAL APPLICATION
; CITY OF FRIDLEY
YOUR E-MAIL ADDRESS •
�wN'-� Warren/Agnes Rollins
❑ OWNER i�oNTRACTOR 6720 211d $tl'22t NrOth2a5t
' . Fridley, MN 55432
,. � 7635747511
STATE LICENSE #
PHONE
]�SINGLE FAMILY
r'
❑ NEW .
DETAILBD DESCRIPTION OF WORK
dB'
EXP DATE
� � ,,...... .,s.�,
- yo33 Fax
�
� TWO FAMILY - p TOWNHOUSE
� REPLACEMENT
Permit No.:
Received By:
ZIP
�
A��� ss�vp'
� PER MS 16B.665 the permit fee is a minim m of $15.00 or 5% of the total cost up to 5500.00; whichever is greater, for the
�: improveraent, installation or replacement of� residential fixture, excluding the fixtures. (Thisshoulcireflect only.the cost of labor )
Labor cost under $340 =$15.00. Labor cost
•ROR;�ROJECTS WEiERE i,ABOR EXCE6DS•�$500;
NUMBER OF EACIi BEIAV�
BATH SINK/LAV FLOOR ;
! BATHTUB � GAS Pil
� CIATHES WASEiER ~ T:ITCHF
! DISHWASHER . -LAUND
Permit
�
" TOTAL DUE
$
Neen $300 to $S00 = cost of labor x.OS =
ARE BASED ON $10.00 PER FIX"�URE, EXCEP�T VJ�iEERE�Ni37�I3..:RIXT:�^�s..(ITfDIGA,TE T.OTAL �
'G nv�ncmucEn+sE)
SINK
'TRAY
THIS IS AN
I hereby apply for a building permit and 1 a
conformance with the ordinances and codes
not a permit but only an applic n for a pe
approved plan in the case 1JA� wl� �
SIGNATURE OF APPLICANT
SHOWER
SWInM�1IIJG POOL
WATER CLOSET
�WATER H�A7'ER (S35)
� WA�R METER
WATER PIPING
WATER SOFTNER (S35)
BACKFLOW PREV. ($IS)
FOR IRRIGATION
+ OTHER
Number of fixtures @ $10.00 x $10,00 = $
Number of fixtures @ $15.00 x $15:00 = $
Number of fixtures @$35.00 � x$35.00 =$ 3S.bo
, State Surcharge = $ S.�'
Total = $ !�i3. ,�
PLICATION FOR A PERMIT-NOT VALID UNTIL PROCESS6D '
nowledge that the information above is complete and accurate; that tha work wfll be in
the City of Fridley and with the Minnesota Construction Codes; that I understand this is
it and work is not to start without a permit; that the work v�rill be in accordance with the
uires review and approval of plans.
� PRINTNAME J� NO/'OIOI�1�1 DATE • �! `�
,
� . City of Fridley
�uilding Inspections Department
6431 �.Jniversity Avenue NE, Fridley, MN 55432
i 7G3-572-3604
�AX: 7f 3-502-4977