P - 45288Building
Inspections
763-572-3604
DATE � �
SITE ADDRESS _ Sawt
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A CpPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
���L�
�
PLUMBING Yernu,��l �7-
RESIIDENTIAL APPLICATION Received By: ��'
' CITY OF FRIDLEY nate Rec'd: �...L 1
YOUR E-MAIL ADDRESS i n�'o (� n�b �c�r✓�- �i7Yvv
a.s ���w Richard Storla
❑ OW[�fER , �ONTRACTOR 7548 Alden Way
N,at�,IE: Fridley, MN 55432
ADDRESS: 7635716726
PI-IONE: '
NAME: �u�lb�i�v
STATE LICENSE # I C> EXP DATE
ADDRESS• �^` � CITY �'
PHONE � — y03 FAX —
�STNGLE FAMILY '�
� NEW
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY
�{REPLACEMENT
L7 TOWN1-IOUSE
CE ZIP
ATE�GIP S�SYO�
� PER MS 16B.665 the pertnit 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, excluding the fixtvres. (T.his.sho�IcLrBflect only.the cost of labor )
Labor cost under $300 =$15.00, Labor cost�between $300 to $500 = cost of labor x.OS =
.%•FOR:�ROJECTS WHERE LABOTt EXCEEDS�$SOO; FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT: WliERE N0'1�D .:Rfi{T�L�R£Ss..(II�FDIC�ATE TOTAL
NUMBER OF EACH BELO� �
BATH SINK/LAV FLOOR D,RAINS SHOWER WATER PIPING
BATHTUB GA$ PIPING fn��cirruceNSE) SWIMMING POOL WATER SOFTNER ($35)
CLOTI�S WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
� DISHWASHER =LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WA i BR METER OTHER
Permit Fee $ ��� Number of fixtures @$10.00 x$10.00 =$
Surchar e , Number of fixtures @$15.00 x$1 S:pO =$
" TOTAL DUE $ _ /�' Number of fixtures @ $35.00 _� x $35.00 = $ 3S.Oo
!�`�!.-� , State Surcharge = $ S • �'
.
Tota1= $ ��
, THIS IS AN IAPPLICATTON FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I a,cknowledge 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 bnt 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. y
SIGNATURE OF APPLICANT PRINT NAME J�'� Nv/QIOWI DATE �� ' o/' I
City of Fridley
B'�,uilding Inspections Department
6431 tJniversity Avenue NE, Fridley, MN 55432
' 763-572-3604
FAX: 763-502-49?7