P - 45004FROM :C�ty o� Fr�dley
Building
Inspections
763-572-3604
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SI'TE �DDRkSS �.,,.�
1"HIS APPLICANI' IS:
PROPERTX r
OWNER/
TENAT�i"C
CONTRACTOR
SUIiI�T A COPY UF
YoUR s'r'a�
LIGENSL• W 1'I"H
� �Pf'LICATION
�ERMIT TYPTti
FAX tJD. :7635712287 Nov. 2B 20@5 10:16AM P4i5
� � ��u \ . �.�,-._..�T.-:
PLUMBING pern�ic No.:�
RESIDENTIA� APPLICATION Rec'e"'ed Qy'�
CITY �F FRI�LEY ���`�
O OWN'ER
YOt1R E-MA[LRDDRESS
CJ'TY
NAME:
STATE UC�E Y�D c� ^ E7� DATB M,
ADDRESS' ...... .- 4fT�,
i�
PHONE ..� ._.. — FAX —_.�....�--G
TYPE OF WORK: � � �W
AT1C, V 71P���
FAMIT.Y O TWO FAMII.Y D TOWNHOUSE
D�rATL�D DESCRiPr{ON OF VvORx
�
PER MS 168.665 tha permit fEe is a mtntmupt of tl S.MI ur S"/o of tbe tot�l cost np to SS00.00, whichever {s greater, far the
{tnprovexnenl, instatlation or reptacement of. a re�id�e! fi�cd:re, exchading @te 5xttms. (This ahould �e�]ecs only dse cost of Iabor )
LSbOf COSL LIDdCI' S:�UU = Sl 5.00. Labor cost betwecn S30d to SS00 - cost of labor _. x.OS 6
FOR PROJF.CI'S wHERE LA230R F.XCEEDS S.WO, FRB5 AkE saSFL o13 Slo.W lp2ft Ftx7'c1RE, EXCIJ'? wHERE NOTED. FtXTl1RF.S; (rNDICATE 7'07'AL
NUMSER OF L•ACH BA.L(1�
BATH SMK/tJ►V FL�OR DRAII�tS SHOW£Jt � WATER PfPING
� RATNI'I.IB (1A3 PIPWU p+EF1iC7riuc� SWIMMIN(3 POOL 1— WATER SOFiNER (S3S)
CLOTHES WASHER � KTI'�ilETl S1MC. AT'ER C�.03ET BACKFLOW P1iBV. (S�S)
_ DISHWASH�R M'� ►.AtJNDFtY 1'RAY �7'fiR H8M'ER (S3� .,.�- FQR LRAt1tiAT10N
, WA'TP.X METER _ ()Tf1FR
Yermit
TUTAL
Namber of 8xtures �y 510.00 x SiO.UQ ° 5.....
Number of fuct�uq � Sl 5,00 ,� x 515.00 = S ._�,_
Number of fixtures � 535.00 � x S35.OQ � S
State 5urcharge - S .50
T�r.t = c
TtitS !S AN APPLiGT10N fOR�Si �('6TtM1•r-NOT v�u.ro urmi. raoc:ssscn
I hardhy appJy for a lwilding permit and I acknawled e thet tbe infoimstion Bbove is campl�txe and accucate; that the w�rk will be in
confurmance with the ordinances and codes ' ity o 'dley snd with the Minn�ota� Consiruc.,tion Cod�s; that I anderxtand this is
not a permit but only aa a�►pii on f it and work is ot m start without a petmit; that the woeic will be in �cordance with the
approved ptan in the case of ch uires review � approval of plt�. �
SIG'NA'fUSL�OF APPI,IGANT ^�PRINf NAME ,_DA'fk��`_,��
, Crty of Fridley
: Bail�ing Inspecti�ns nepartmer�t
6431 University Avenue NE, Fridley, MN 55432
_ 763-572-36U4
FAX: 763-502-4977