P - 42746) .
Building ' PLUMBING Permit No.: 3b
Inspections - �SI!DENTIAL APPLICATION Received By: �1i
763-572-3604 CITY OF FRIDLEY Dat��:�. �� ����
DATE I l ( � YOUR E-MAIL ADDRESS
SIT'E ADDRESS __ e.wtL �.s 0��,.�� lean/ScottGrussing
THIS APPLICANT IS: ❑ OWNER ', �ONTRACTOR 158 63rd Way Northeast
PROPERTY N�E. ' Fridley, MN 55432
�W�� twDRESS: 7635712876 ATE ZIP
TENANT
• PHONE:
CONTRACTOR NAME:
SUBMIT A CQPY OF STATE LICENSE # C% EXP DATE
YOUR STATE ADDRESS� � ti � CITY �' .rl /,f STATE�L�LIP S�SyO�
LICENSE WITH , pHONE 7— y03 FAX
APPLICATION : - �
PERMIT TYPE �SINGLE FAMILY ' ❑ TWO FAMILY - 0 TOWNHOUSE
TYPE OF WORK: ❑ �W � ', ��PLACEMENT
DETAILED DESCRIPTION OF WORK
PER MS 16B.665 the permit fee is a minim m of $15.00 or 5% of the total cost up to �500.00; whichever is greater, for the
improvement, insta.11ation or replacement of� residential fixture, excluding the fixtures. (This.shoulcLrEflect only.the cost of labor )
Labor cost under $300 =$15.00. Labor cost�between $300 to $500 = cost of labor x.OS =
>:FOREROJECTS WHERE LABOR EXCEEDS°$500;�?EES ARE B,43ED ON $10.00 PER FIXTURE, EXCEPT:WHEItE NU.'1�3�..:Rt)CT'i,ii��:,..(II3DIGA.TE TO�TAL
NUMBER OF EACH BELO�
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING �ve�c�rruc�,rsE) SWIMMING POOL WATER SOFTNER ($35)
i CLOTHES WASHER i KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER =LAUNDRY TRAY LWATER HEATER ($35) FOR IRRIGATION
� , WATER METER _ OTHER
Permit Fee $ Number of fixtures @$10.00 x$10,00 =$
Surchar e .50 Number of fixtures @$15.00 x$15:00 =$.
TOTAL DUE $ Number of fixtures @$35.00 � x$35.00 =$ 3S,Oo
' , State Surcharge = $ 5��'
Tota1= $ . . .�
THIS IS AN IAPPLICATION FOR A PERMIT-NOT VALID UNTIL PROCE55ED
I hereby apply for a building permit and I a�'clmowledge that the information above is complete and accurate; that the work will be in
conformarrce 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 applic ' n for a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case 1 o w' � uires review and approval of plans.
� 1 ��/ t� 15 � v
SIGNATURE OF APPLICANT ! PRINT NAME Je. /Vd/b/ON�I DATE '
I
City of Fridley
�uilding Inspections Department
6431 l� Tniversity Avenue NE, Fridley, MN 55432
' 7f3-572-3604
FAX: 763-502-4977