P - 35480I
Building PLUMBING Permit No.: ��b dti
Inspections � RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY D��'��`�
DATE � O YOUR E-MAIL ADDRESS
si�,�DttESS _$a�� �a D��w GeneHeglund
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR 7320 Concerto Curve
PROPERTY N�: . Fridley, MN 55432
�W�� ADDRESS: 7637843568 ZiP
TENANT
• PHONE:
CONTRACTOR NAME:
SUBMIT A CQPY OF STATE LICENSE # C> EXP DATE
YOUR STATE ADDRESS� f^i CITY i' ! /t STATE�LIP S�S�YO�
LICENSE WITH , pHONE 7- Y03 FAX �-
APPLICATION - �
PERMIT TYPE �iSINGLE FAMILY ❑ TWO FAMILY - � TOWNt-IOUSE
TYPE OF WORK: � �W ' � �REPLACEMENT
DETAILED DESCRIPTION OF WORK
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
: impro�ement, installation or replacement of a residential fixture, excluding the fixtures. (T.his.shoul�reflect only.the cost of labor )
Labor cost under $300 =$15.00. Labor cost between $300 to $SOU = cost of labor x.OS =
� FOR�ROJECTS WHERE LABOR EXCEEDS�SOO;�FEES ARE BASED ON $10.00 PER FIXTURE,�EXCEPT Vi�HEL2E N�'I�D .:FI}C'F�S: .(INDICA�TE TQTAL ���
NUMBER OF EACH BEIAV�
_-------------=---- -- --- - -
_ BATH S1NK/LAV _.__. __ . ___ -_FLAOR DRAINS_ _. ___ . _ _ SHOWER . _ _ _ WATER PIPING
BATHTUB GAS PIPING ��ocrnuc�rsE) SWIMMING POOL WATER SOFTNER ($35)
CLOTi�S WASHER KITCHEN SINK WATER CLOSET � BACKFLOW PREV. ($15)
DISHWASHER _.LAUNDRY TR�Y �WATER H�ATER (S35) FOR IRRIGATION
WATER METER OTHER
Permit Fee $ Number of fixtures @$10.00 x$10.00 =$
Surchar e .50 Number of fixtures @$15.00 x$1S:U0 °$
TOTAL DUE $ Number of fixtures @$35.00 � x$35.00 =$ 3S.Oo
... _ , State Surcharge = $ `"
Tota1= $
THIS IS AN APPLICATION FOR A PERMIT NOT VALID UNT1L PROCESSED '
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformauce 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 v�rill be in accordance with the
approved plan in the case 1 o w' r ires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME ��� NO/b/0I'YI DATE �(� LV I ��
. City of Fridley
Buildia�g Ins�ections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-49?7