P - 35467Building
Inspections
763-572-3604
DATE I l 1 I:'� [J
i
SITE ADD SS �„�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
SUBMIT A CpPY OF
YOURSTATE
LICENSE WITH ;
APPLICATION � �
PERMIT' TYPE
�
PLUMBING
RESIiDENTIAL APPLICATION
' CITY OF FRIDLEY
' YOUR E-MAIL ADDRESS
p,,,,,��,,,r JeffThorp
❑ OWNER '', �ONTRACTOR 170 Craig Way Northeast
i Fridley, MN 55432
7635740829
STA'fE LICENSE
PHONE
]i�SINGLE FAMILY
�-
TYPE OF WORK: I � �W
DETAILED DESCRIPTION OF WORK
� P/u.r�6i�4
Ci EXP DATE
� I C1TY �'
- yo33 Fax _ `
� TWO FAMILY
�REPLACEMENT
� TOWN3-IOUSE
Permit No.:
Received By:
Date
A1'E ZIP,
'ATE�p ss'Y
�
� PER MS 168.665 the permit fee is a minim ' m of $15.00 or 5% of the total cost up to 5500.00; whichever is greater, for the
�: impro�ement, insta.11ation or replacement of residential fixture, excluding the fixtures. (This.shouldreflect only.the cost of labor )
Labor cost under $300 =$15.00. Labor cost between $300 to $500 = cost of labor x.OS =
.� ��•ROR�3.'ROJEGTS W[�RE LABOR EXCEEDS�500;�ES ARE BASED ON $10.00 PER FIXTURE, EXCEP'f;'WHERE�NC�.:G�L'l..:RIXT��: .(INDIC�,A,TE TQTAL
NUMBER OF EACH BELOV� .
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPRJG
BATHTUB GAS PtPING pr�o cmuCExsE) SWIMMING POOL WATER SOFTNER ($35)
^ CIATI�SIWASHER KITCHE2� SINK WATER CLOSET BACKFLOW PREV. ($15)
i DISHWASHER _.LAUND IY TR�Y LWATER HEATER ($35) r FOR IRRIGATION
WATER MEfER OTHER
Permit Fee
�
" TOTAL
$ I Number of fixtures @$10.00 x$10,00 =$.
I.50 Number of fixtures @$15.00 x$15.D0 =$
$ Number of fixtures @ $35.00 � x $35.00 = $.
. . . . . ' , State Surcharge = g
Tota1= $
THIS IS AN
I hereby apply for a building permit and I a
conformarrce with the ordinances and codes
not a permit but only an apptic ' n for a pe
approved plan in the case l o w' �
SIGNATURE OF APPLICANT
.ICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED '
�wledge that the information above is complete and accurate; that the work wfll be in
e City of Fridley and with the Minnesota Construction Codes; that I understand this is
and work is not to start without a perrnit; that the work will be in accordance with the
res� w and approval of plans. l
PRINTNAME JL NO/D/DN�I DATE �'I� V
City of Fridley
uilding Inspections Department
6431 , niversity Avenue NE, Fridley, MN 55432
� 763-572-3604
FAX: 763-502-49?7