P - 35588J .
Building PLUMBING Permit rlo.: -
Inspections j�SI�DENTIAL APPLICATION Received By:
763-572-3604 ; CITY OF FRIDLE� Date xec'd:� c�- �(
DATE_ 1'� f t I YOUR E-MAIL ADDRESS
SrrEa,DDRESS $a�� �..s �.��.wF Walter/Gloria Czerepak
THIS APPLICANT IS: ❑ OWNER ;�oN' 6220 7th Street Northeast
PROPERTY N,�: ' Fridley, MN 55432
OWNER/ �D�SS: 7635711644 STATE z�P
TENANT
• PHONE:
CONTRACTOR NAME:
SUBMIT A G(�PY OF STATE LICENSE # � C% EXP DATE
YOUR S1'ATE ADDRESS• ��ti � CITY .' �l STATE�LIP Srf'YO�
LICENSE WITH , pHONE — Y03 FAX
APPLICATION 4 �
PERMIT' TYPE �SINGLE FAMILY j ❑ TWO FAMILY -' O TOWNHOUSE
i
'i
TYPE OF WORK: � �W ' I� � ��PLACEMENT •
DETAILED DESCRIPTION OF WORK
�
• PER NiS 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, installation or replacement of� residential fixture, excluding the fixtures. (This.sho.ul�reflect only.the cost of labor )
Labor cost under $300 =$15.00. Labor cost between $300 to $500 = cost of labor x.05 =
.��• �°.FOR�ROJEC`fs WHERE L;4BOR EXCEEDS•�$3UO;�ES ARE BASED ON $10.00 PER FIXTURE, EXCEP�TW�ILE'NO.'I�II..:R[�C1':t�R-ES: .(II3DIC�.TE TOTAL � •
NUMBER OF EACH BELAWj
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
r BATHTLB GA$ PIPING pv�ct�rt�CErtsE) SWIMMING POOL � WATER SOFTNER (S35)
`CLATEIES WASHER KITCHEI�i SINK WATER CLOSET BACKFLOW PREV. ($1�
DISHWASHER =LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
I _ WATER METER _ OTHER
Permit Fee $ .� Number af fixtures @$10.00 x$10.00 =$
Surchar e "' .50 Number of fixtures @ $15.00 x $1 �sAO = $
TOTAL DUE $ Number of fixtures @$3�5.00 � x$35.00 =$ 3S.Oo
.. . _ . �' , State Surchazge = $ �.�'
Tota1= $ �
THIS IS AN PLICATION FOR A PERMIT-NOT VALID UNTIL PROCE35ED '
I hereby apply for a building permit and I a�clrnowledge that the information above is complete and accurate; that the work will be in
conformarnce with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permitbut only an applic ' n for a pe} �. it 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.
SIGNATURE OF APPLICANT PRINT NAME J�'� NO/�I0I�1�I DATE �1 Z% �� I
City of Fridley
uilding Inspections Department
6431 niversity Avenue NE, Fridley, MN 55432
: 763�572-3604
FAX: 753-502-49?7