P - 48157Building
Inspections
763-572-3604
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A CQPY OF
YOUR STATE
LICENSE WITH ,
PERMIT' TYPE
TYPE OF WORK:
7 .
' PLUMBING
RESIiDENTIAL APPLICATION
' CITY OF FRIDLEY
" YOUR E-MAIL ADDRESS
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0 owt�tEtt i�oN1'x.�c'ro�t Lu i s G i ro n
5830 Stinson Boulevard
�: , Fridley, MN 55432
I 7633571070
STATE LICENSE #_
ADDRESS•
PHONE,�S1�?�
�SINGLE FAMILY
❑ NEW .
DETAILED DESCRIPTION OF WORK
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Permit No.:�
Received By:
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I
�_ EXP DATE
F�A��CITY i' /1 STATE�i � IP r��
a22� ��2 ,
- � TOWNHOUSE �
� REPLACEMENT
� PER MS 16B.665 the permit fee is a minim m of $15.00 or 5% of the totai cost up to 5500.00; whichever is greater, for the
�: impro�ement, installation or replacement of� residential fixture, excluding the fixtures. (This shoail�rEflect only:the cost of labor )
Labor cost under $300 =$15.00. Labor cost between $300 to $500 = cost of labor x.OS =
� �
.:• �':ROR3.'ROJEGTS WHERE L;4BOIt EXCEEDS•�300;�EES ARE BASED ON $10.00 PER FIXTURE,'EXCEP�T�A�3ERE�P�.'C.�i�..:RI3CF:d�R�E�:..(IT+�DIG,ATE TOTAL � �
NUMBER OF EACH BEIAV� � .
. BATH SIldK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIP �ING (n��o crrv�rcErvsE) SWIMMING POOL WATER SOFTNER (S35)
CIATHES WASHER TCITCHEN SMK WATER CLOSET � BACKFLOW PREV. ($15)
_,DISHWASHER =LAUND IY TRAY �WATER HEATER ($35) _ FOR IRRIGATION
WATER METER OTHER
�
Fee
Number of fixtures (a� $10.00 x $10.00 = $
I.50 Number of fixtures @$15.00 x$15'.A0 =$
Number of fixtures @$35.00 � x$35.00 =$ 3S Oo
. . . . : '' , State Surcharge = $ S,�'
'� Total = $ �,�
THIS IS AN
I hereby apgly for a building permit and I a
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' �
SIGNATiJRE OF APPLICANT
PLICATION FOR A PERMTf-NOT VALID UNTIL PROCESSED '
nowledge that the information above is complate and accurate; that the work will be in
the City of Fridley and with the Minnesota Construction Codes; that I understand this is
�t and work is not to start without a permit; that the work will be in accordance with the
uues review and approval of plans.
� PRINTNAME Jt NO/�blDi'Yl DATE � '� � �
City of Fridley
6431��uilding Inspections Department
.Tniversity Avenue NE, Fridley, MN 55432
� 763-572-3604
' rAX: 763-502-4977
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