P - 44972Building
Inspections
763-572-3604
) .
PLUMBING
RESI�DENTIAL APPLICATION
', CITY OF FRIDLEY
DATE_ �_ f�(f ! 1 I YOUR E-MAIL ADDRESS
SITE ADDRESS _Se.wtL ar.s Dus�t,✓t
THIS APPLICANT IS: ❑ OWNER ', �ONTRACTOR Duane Retzer
PROPERTY 6431 Squire Drive
N'atvrE: Fridle , MN 55432
TEN�T ,4nDRESS: 7635749559
CONTRACTOR
SUBMIT A CQPY OF
YOUR STATE
LICENSE WITH .
APPLICATION
PERMIT' TYPE
STATE LICENSE #
�o
EXP DATE
� � ...�.., �,
PHONE �G / Z) S2 %� y033 � FAX
]�SINGLE FAMILY II� ❑ TWO FAMILY
��
TYPE OF WORK; I � �W
DETAILED DESCRIPTION OF WORK
�REPLACEMENT
0
O TOWNHOUSE
Permit No.:
Received By;/�%l�('
Da���'d�Q� � �
�1'E ZIP
�
, ssyo
� PER MS 16B.665 the permit fee is a minim m of $15.00 or 5% of the total cost up ta �500.00; whichever is greater, for the
: impro�ement, installation or replacement of� residential fixture, excluding the fixtures. (This.shouldreflect only.the cost of labor )
� .
Labor cost under $300 =$15.00. Labor cost between $300 to $SOU = cost of Iabor x.OS =
.�>•ROR�ROJEGI'•S WHERE LABOR EXCEED3°�500;�EES ARE BASED ON $10.00 PER FIXTURE, EXCEPT W;EIEEtE�NQ'[�i3.:F[XT��:..(ZNI3IC�,TE T.QTAL �
NUMBER OF EACH BEIAV� �
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTU$ GAS PIP �ING (�v�nC�rYUCenrst) SWIMMIIJG POOL WATER SOFTNER (S35)
� CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER =LAUNDRY TRAY ,_(_WATER HEATER ($35) FOR IRRIGATION
; _ WATER METER _ OTHER
�
0
Fee
$
THIS IS AN
I hereby apply for a building permit and I�
conformarrce with the ordinances and codes
not a permit but only an applic n for a pe
approved plan in the case 1�6osjc whj� �
SIGNATURE OF APPLICANT
/
Number of fixtures @ 510.00 x$10.00 =$
.50 Number of fiactures @ $15.00 x $15',UO = $
Number of fixtures @ $3�5.00 � x $35.OU = $
, State Surcharge = 9
Tota1= $
.1CATION FOR A PERMIT-NOT VAL[D UNTIL PROCESSED '
�wledge that the information above is complete and accurate; that the work w�ll 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 will be in accordance with the
res review and approval of plans.
'' PRINT NAME JC NBI��IDN�I DATE I/—`-'" / v`
__I City of Fridley
l�uilding Inspections Department
6431 l,�Jniversity Avenue NE, Fridley, MN 55432
' 763-572-3604 .
FAX: 763-502-4977