P - 42831) .
Building PLUMBING Permit No.:
Inspections - j�SIIDENTIAL APPLICATION Received s:
763-572-3604 ; CITY OF FRIDLE� r�ate xec . �' �
DATE YOUR E-MAIL ADDRESS
sr['�,�DRESS $d�t aa ��N�,.w; Larry Korzenowski
THIS APPLICANT IS: ❑ OWNER ',' �ONTRACTOR 529 Janesville Street
PROPERTY N,y�,�E_ ' Fridley, MN 55432
�W�� ,�,�DRESS: 7637865291 I'ATE ZIP
TENANT
� PHONE:
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # Si%, EXP DATE
YOUR STATE ADDRESS• I'ti I CITY �' ! iJ STATE�LIP SS�YO�
LICENSE WITH , pHONE 7— y03 FAX
APPLICATION ° �
�
PERMIT TYPE �SINGLE FAMILY '', ❑ TWO FAMILY - O TdWNHOUSE
TYPE OF WORK: � �W ', ��PLACEMENT
DETAILED DESCRIPTION OF WORK �
�I
PER MS 16B.665 the permit fee is a miniraum 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 fixture, excluding the fixtures. (This.shouldr.eflect only.the cost of labor )
Labor cost under $300 =$15.00. Labor costlbetween $300 to $500 = cost of labor x.OS =
�'�FOR:EROJECTS WHERE LABOR EXCEEDS.$SOO;�EES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERB NQ"i�I3..:R[I�'F�^�:..(INDIGI�TE TOTAL
NUMBER OF EACH BELOV�
BATH SINK/LAV _FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GA$ PIPING p✓eEDCt�r!✓Cer�sE) SWIMMING POOL WATER SOFTNER ($35)
i CLOTHES WASHER ^ KITCHEN 3MK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER =-LAUNDRY TRAY �,WATER HEATER ($35) FOR TRRIGATION
� WATER METER OTHER
Permit Fee $ Number of fixiures @$10.00 x$10.00 =$
Swc�ar e '.50 Number of fixtures @$I5.00 x$1Sap0 =$
TOTAL DUE $ Number of fixtures @$35.00 � x$35.00 =$ 3S.Oo
, State Surcharge = $ 5 � �'
Tota1= $ ,�
THIS IS AN I�PLICATION FOR A PERMTI'-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 Constructi�n 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 will be in accordance with the
approved plan in the case 1 o w' r uires review and approval of plans.
SIGNATURE OF APPLICANT I PRINT NAME J�'� NO/D /OI�:�I DATE � O� ��
City of Fridley
��uilding Inspections Department
6431 �Tniversity Avenue NE, Fridley, MN 55432
' 763-572-3604
FAX: 763-502-4977