P - 36729Building
Inspections
763-572-3604
�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
SUBMIT A CQPY OF
YOUR STATE
LICENSE WITH
PERMIT' TYPE
�
' PLUMBING
RESIi�DENTIAL APPLICATION
' CITY OF FRIDLE�
Permit No.:
Rece �ved By: � °
LiCl't�'�ec'�`�y v 2 � �
YOUR E-MAIL ADDRESS
�c�stiea/t � .
❑ OW[�IER ', �ONTRACTOR �oan McLaughlin
1050 Gardena Avenue Northeast
Fridley, MN 55432
'� 7635713165 �'tATE ziP
STATE LICENSE #__
PHONE
�SMGLE FAMILY
TYPE OF WORK: I � ��'�'
DETATLED DESCRIPTION OF WORK
� /�/u.r�bi�o
C> EXP DATE
�t9t i' � CITY �'
- yo33 FAx
❑ TWO FAMILY - 0 TOWNHOUSE
� REPLACEMENT �
. . . ., i
7'E�LIP f�0�
� PER MS I6B.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.shouldceflect only.the cost of labor )
Labor cost under $300 =$15.00. Labor costlbetween $300 to $500 = cost of Iabor x.OS =
.FOR�ROJEGTS WHERE l.ABOR
NUMBER OF EACH BELOV�
BATH SINK/LAV
BATHTUB
_ CIATHES' W ASHER
lDISHWASHER
Fee
w TOTAL DUE
ARE BASED ON $10.00 PER FIXTURE, EXCEPT'VJ;[3ExE'N'O• .'1�i�...:RIXT3�l��;,..(iNDIC�s.TE T.UTAL I �
FLAOR DItAINS
GAS PIP �ING pveEOCtrrt�c�sE)
KITCHEN SMK
_ LAUNDRY TRAY
$
' .50
$
�
THIS IS AN
I hereby apply for a building permit and I a
conformance with the ordinances and codes
not a permit but only an applic ' n for a pe
approved plan in the case 1 o w' �
SIGNATURE OF AP?LICANT
SHOWER
SWIMMING POOL
WATER CLASET
�WATER HEATER ($35)
_ WA'i'ER METER
WATER PIPING
WATER SOFTNER ($35)
' BACKFLOW PREV. ($15)
FOR IRRIGATION
,_ OTHER
Number of fixtures @ $10.00 x $10.00 = $.
Number of fixtures (a3 $i5.00 x $]S�UO = $,
Number of fixtures @ $35.00 � x $35.00 = $,
State Surcharge = $
rotal= $
PLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED '
nowledge that the information above is complete and accurate; that the work will be in
the CiTy of Fridley and with the Minnesota Construction Codes; that I understand this is
it and work is not to start without a permit; that the work will be in accordance with the
uires review and approval of plans.
� rR]NTNAME Jt'� NO/�IIN�I )ATE t ( ! �" 1 � �
. City of Fridley
� �uilding Ins�ections Department
6431 �.Tniversity Avenue NE, Fridley, MN 55432
' 7G3-572-3604
' FAX: 763-502-4977