P - 48119Building
Inspections
763-572-3604
DATE 5j3�
si� a,D�x�ss S
1'HIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A CpPY OF
YOUR S�fATE
LICENSE WITH
PERMIT' TYPE
TYPE OF WORK:
) .
' PLUMBING
RESIiDENTIAL APPLICATION
' CITY OF FRIDLE�
YOUR E-MAIL ADDRESS
�..+�,.wr John/Jacquely Linstrom
❑ owrr�t ; �orr'rx.�CTOR 5551 Waleck Crossing
, Fridley, MN 55432
, 7635741430
STATE LICENSE #_
ADDRESS•
PHONE ,�5��?�
�SINGLE FAMILY
❑ NEW .
DETAILED DESCRIPTION OF WORK
��/ur>6irlo
�l� EXP DATE
t� � CITY i'
- yo33 Fax '
❑ TWO FAMILY
, �REPLACEMENT
� TOWNHOUSE
Permit N
Received B
ZIP
ATE�LIP S�YO
,
� 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
�: impro�ement, installation or replacement of� residential fixture, excluding the fixtures. (This.should.reflect only.the cost of labor )
Labor cost under $300 = $15.00. Labor
.FOR�.'ROJEC`I'S WHERE LABOR EXCEEDS°$500;
NUMBER OF EACH BEIAV�
BATH SWK/LAV _FLAOR
BATHTUB GAS PI]
C1A'fI-IESIWASHER KITCHI
DISHWASHER �LAUN�
Fee
�
� TOTAL DUE
�veen $300 to $500 = cost of labor x .OS = -
ARE BIi.SED ON $10.00 PER FII�TURE, EXCEP�'i"W�f3ERE�NC.L'[�iL�...:FlIC'F:�S:..(ii�}DIC7ATE TO�TAL
fG Rr�ocrrrt�CEtvsE)
SMK
'TRAY
SHOWER
SWIMMING POOL
WATER CLOSET
,LWATER HEATER (S35)
_ WAZ'ER METER
WATER PIPING
WATER SOFTNER ($35)
BACKFiOW PREV. ($1�
FOR IRRIGATION
_ OTHER
! Number of fixtures @ $10.00 x $10.00 = $
; .50 Number of fixtures @ $15.00 x $15�D0 = $
Number of fixtures @ $35.00 ,� x $35.00 = $
, . . . . '' , State Surcharge = 9
�i Tntal = P.
TfiIS IS AN
I hereby apgly for a building permit and I a
conformaiTCe with the ordinances and codes
not a permit but only an applic n for a pe
approved plan in the case I�rD� whj� �
SIGNATURE QF APPLICANT
PLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED '
aowledge that the information above is complete and accurate; that the work w�ll 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.
✓r PRINTNAME J� NO/DIDH�► DATE���_
City of Fridley
uilding Inspections Department
6431�niversi Avenue NE, Fridle MN 55432
� tY Y�
i 763-572-3604
, FAX: 763-502-4977