P - 48059Building
Inspections
763-572-3604
DATE 5
SITE ADDRESS
7'HIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION �
PERMIT TYPE
TYPE OF WORK:
) .
' PLUMBING
RESIiDENTIAL APPLICATION
� ' CITY OF FRIDLE�
YOUR E-MAIL ADDRESS __ ����
°`s �"""`a'r Sandra Swanson
❑ OWNER ', �ONTRACTOR 450 Hugo Street
ri,�tvtE: " Fridley, MN 55432
�DRESS: 7637869614
aunuF•
STATE LICENSE #_�
ADDRESS• i
PHONE 7 —
�SINGLE FAMILY I
�-
❑ rrEw .
DETAILED DESCRIPTION OF WORK
EXP DATE
� CITY�'y,
FAX —
❑ TWO FAMILY
�REPLACEMENT
a TOWNI-IOUSE
Permit No.:
Received By:
�
1`E ZIP
A��/i�P ssyoq
� 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 a residential fixiure, excluding the fixtures. (This.shou]c�r.Eflect only.the cost of labor )
Labor cost under $300 =$15.00. Labor cost�between $300 to $500 = cost of labor x.OS =
<�' ROR:PROJEGTS WHERE LA$OR EXCEEDS �$500; F�EES ARE BASED ON $10.00 PER FIXTURE, EXCEPT: WHERB N0'I:ED..: RTXT�UR-E�:.-(INDIGATE TOTAL
NUMBER OF EACH BELOV� '
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
_ BATHTUB GAS PIPING (n��ct�rLrC�sE) SWIMMING POOL WATER SOFTNER ($35)
_ CLOTHES WASHER _ KITCHEN 3INK WATER CLOSET BACKFLOW PREV. ($15)
_.DISHWASHER =-LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
', _ WATER METER _ OTHER
Permit Fee $
` TOTAL DUE
.50
Number of fixtures @ $10.00 x $10.00 = $
Number of fixtures @$15.00 x$1 S':DO =$
Number of fixtures @$35.00 � x$35.00 =$ 3S.po
State Surcharge = $ S • �='
Total = $ � ��
THIS IS AN iAPPLICATION 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 Consiruction Codes; that I understand this is
not a permit but only an applic ' n for a permit and work is not to stark without a permit; that the work will be in accordance with the
approved plan in the case 1 o w' n uires review and approval of plans.
SIGNATURE OF APPLICANT ! PRINT NAME J�"'� NO/�IDI':�J DATE �+ ��� ��
City of Fridley
B',uilding Inspections Department
6431 University Av�nue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977