P - 35589Building
Inspections
763-572-3604
sr�,AnDx�ss _J
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A CQPY OF
YOUR STATE
LICENSE WITH
)
' PLUMBING
RESI!DENTIAL APPLICATION
' CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
����h Carol Klein
❑ owt�rEtz I�ONTRACTC 6527 Monroe Street North
;� Fridley, MN 55432
_ 6122516527
STATE LICENSE
PHONE
PERMIT' TYPE �SINGLE FAMILY
TYPE OF WORK: � �v`'
DETAILED DESCRIPTION OF WORK
7 /�/un�6i��
CJ EXP DATE
__�r i' � CITY �'
- yo33 Fax -'
❑ TWO FAMILY
� REPLACEMENT
O TOWNHOUSE
Permit No. ���
Received By: �
Date Rec'd: �a-q `/
STATE ZIP
ATE�LIP S��O�
• PER MS 16B.665 the permit fee is a minim m of $15.00 or 5°/a of the total cost up to $500.00; whichever is greater, for the
: improvement, installation or replacement of� residential fixture, excluding the fixtures. (This.sho.uldreflect only.the cost of labor )
Labor cost under $300 =$ I5.00. Labor cost between $300 to $500 = cost of labor x.OS =
.�• =�ROR�ROJEGTS WHERE LABOR EXCEEDS°$5U0;
NUMBER OF EACH BEIAV�
BATH SINK/LAV _FLOOR
BATHTLfB GAS PIl
CIATf�S WASHER KITCH]
DISHWASHER -LAUNC
Permit Fee $ _
Surcharge
" TOTAL DUE $
;ES ARE BASED ON $10.00 PER FIXTURE, EXCEP'�"WHE1tE�I�Ti�'1�D�.:RIIC'F.�R�ES:...(iNDIC�A.TE TQTAL �
AINS SHOWER WATER PIPING
fG (n��vci�r�✓cEnrsE) SWIMMING POOL � WATER SOFTNER ($35)
SINK WATER CLOSET ^ BACKFLOW PREV. ($15)
' TRAY �WATER HEATER ($35) FOR IRRIGATION
_ WATER METER _ OTHER
J Number of fixtures @$10.00 x$10.00 =�,
i.50 Number of fixtures Q$15.00 x$15',OU =$,
Number of fixtures @ $35.00 ,�_ x $35.00 = $
. '', . State Surcharge = 9
' Total = $
THIS IS AN
I hereby apply for a building permit and I z
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 APPLICANT
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.
� PRINTNAME JC. /VO/D/OI�M► DATE 7/�(.� L �I
City of Fridley
6431�uilding Inspections Department
niversity Avenue NE, Fridley, MN 55432
'� 763-572-3604 -
' FAX: 763-502-4977