P - 42379Building PLUMBING Permit N.:` � i� �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY D��'�. 6 201
DATE °t�v 7! cl �! dC( (� YOUR E-MAIL ADDRESS �GS y»�( (/� �j mc.�►��7'� • utT�
SITE ADDRESS Srg3" ? St`' ,T�''N'�"
THIS APPLICANT 1S: �7AWNER ❑CONTRACTOR
PROPERTY TfAME: � o A�+ticl.e �(
OWNER/ ADDRESS: .,� S% S f" r ,,,./ ��y
CITY !"/L er.� �e #I STAT� ZIP�,�+' �
TENANT
PHONE: 7�a ,�• s �� . •y� o
CONTRACTOR NAME:
S[JBMIT A COPY OF STATE LICENSE # £XP DATE
YOL3R STATE ADDRESS: CITY STATE ZIP
LICENSE WITH PHONE FAX
APPLICATION
PERMIT TYPE ��NGLE FAMILY ❑ TWO FAMILY ❑ TOWTVHOUSE
TYPE OF WORK: � NEW l�,REPLACEMENT
DETAILED DESCRIPTION OF WORK /t�/�'4�+2��5 ��er►•adtji%�y ��9;it''/�tcn�'/'�.!-��2oare�t
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PER MS 16B.665 the permit fee is a minimum of �15.00 or 5% of the total cost up to $500.00, whichever is greater, for the __. _.
improvement, installation or replacement of a residential fixture, exc{uding the fixtures. (This should reflect only the cost of labor )
Labor cost under $300 =$15.00. Labor cost between $300 to $500 = cost of labor x.OS =
FOR PROJECTS WHERE LABOR EXCEEDS $SpO, FEES ARE BASED ON $10.00 P£R FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL
NUMBER OF EACH BELOW)
� BATH SfNK/LAV /r1r+�� �FLOOR DRAINS �e�lAr,,KS SHOWER WATER PIPING
1 BATHTUB �ytvu� GAS PIPING �ti�i:i:i�rin i.��•i:NSi:) SWIMMMG POOL � WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
^ DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) ^ FOR IRRIGATION
! WATER METER OTHER
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Permit Pee $ f _S . �-- Number of fixtures @ $10.00 �_ x„$10.00 = $ �7'v °=
Surchar e .50 Number of fixtures @$ I 5.00 x$15.00 =$
TOTAL DUE $ �.� Number of fixtures @ $35.00 �_ x $35.00 ° $ -���
State Surcharge — $ 50
Tota1= $
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED '
I hereby apply for a building permit and ( acknowledge that the information above is complete and accurate; that the work wi e 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 perinit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work which requires review and approval of plans. '��d��a�d
Q� r ..--, ` �)
SIGNATURE OF APPLfCANT � V�J'd�f JAx�Q PRI.NT NAME I t1��s<}-+t�Ptl DAT��d
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City of Fridley �
Building Inspectio�s Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 .
FAX: 763-502-4977