P - 36731�e
Building
Inspections
763-572-3604
7 .
' PLUMBING
RESIiDENTIAL APPLICATION
' CITY OF FRIDLEY
1�A7 �_ - �("{�1 1 YOUR E-MAIL ADDRESS
SITE ADDRESS _Sn„vtL ar.s ��.sr.w
THIS APPLICANT IS: ❑ OWNER ;�ONTRACTOR Don Foreman
PROPERTY ; 7092 Hickory Drive
pW�� Na�t�E' Fridley, MN 55432
TENANT �D�ss: ', 7635720259
SUBMIT A CQPY OF
YOUR S1"ATE
LICENSE WITH
PERMIT! TYPE
TYPE OF WORK:
STATE LICENSE #_
ADDRESS•
PHONE ,�;� [�
�SINGLE FAMILY
❑ NEW .
DETAILED DESCRIPTION OF WORK
d0'
�-- EXP DATE
/�./ /'/. �� f' ,,...... .�sil .
- yo33 FAx
0
❑ TWO FAMILY - d TOWNHOUSE
�REPLACEMENT
Permit No.:
Received By:
n,+e �o��a.
ATE ZIP,
A7'E�LIP sSYO�
PER MS 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.shouldieflect only.the cost of labor )
Labor cost under $300 =$15.00. Labor cost between $300 to $500 = cost of labor x.OS =
i
��UR�ROJEC`T5 WHERE LABOR EXCEEDS�SUO;�ES ARE BASED ON $10.00 PER FTXTURE, EXCEP�T'W[�RE'PlCT,T;[�i3..:RTX'�ItE�:..(INDIC�TE TUTAL �
NUMBER OF EACH BELOVi� �
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING �nr�vcirruc�rsE) SWIMMING POOL WATER SOFTNER (S35)
_CLOTI-!ES'WASHER KITCHEI� SMK WATER CIASET BACKFLOW PREV. ($15)
iDISHWASHER =LAUNDRY TRAY �WATER HEATER ($35) FQR IRRIGATION
; _ WATER METER _ OTHER
Fee $
" TOTAL DUE
50
THIS IS AN
I hereby apply for a building permit and I a
conformacrce with the ordinances and codes
not a permit but only an applic ' n for a pe
approved plan in the case 1�r6� wh'yc� �
SIGNATURE OF APPLICANT
Number of fixtures @ $10.00 x $10,00 = $
Number of fixtures @ $15.00 x $15,00 = $
Number of fixtures Q$35.00 � x$35.00 =$ 3S.Oo
, State Surcharge = $�_
Total = $ �.�
.ICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED '
�wledge that the information above is complete and accurate; that the work will 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 permit; that the work vuill be in accordance with the
res review and approval of plans.
�r PRINTNAME ��'C'� NO/D/DIN! DATE � � �
' City of Fridley
uilding Inspections Department
6431 , niversity Avenue NE, Fridley, MN 55432
I 763-572-3604
� FAX: 753-502-4977