PRE 2010 DOCSDate: — ,dune 21. 1967
Owner: DAVE OLSON
City of Fridley, 1Vtinn..
UILDING PERMIT
N° .9327
Builder NJELDAN_BUILDERS, INC.
Address 144 Rice Creek Road Address 6333 Georgia Avenue North
LOCATION OF BUILDING
NO. ._ x.19 Street Rickard Road part of Lot
Lot _ 2 Block 1 Addition or Sub -Division Garten's Addn.
Corner Lot Inside Lot X Setback 35' --- Sideyard 10'
Sewer Elevation ___ 851.10 1 M986K WSW= 854.10
Top of Footing
DESCRIPTION OF BUILDING
To be Used as:
Dwelling, Front50' Depth 26'6' Height 20' Sq. Ft1300 Cu, Ft
Garage Front 22' Depth 22' Height 10' Sq. Ft. Cu. Ft.
Type of Construction Frame Est Cost $14, 700 To be Completed Noy.1, 1967
SEWER. LOCATION - 114' East of Manhole
WATER LOCATION - 10' East of Sewer
In consideration of the issuance to me of a permit to construct the building described above I agree to do
the proposed work in accordance with the description above set forth and In compliance with a'll provisions of
ordinances of the city of Fridley. ��7���✓�✓�� .
00.00 NSSSD %Yt—A
In consideration of the payment of a fee of $__2 —1- 0 0 permit is hereby granted to Meldan Blders .
to construct the building or addition as described above. This permit is granted upon
the express condition that the person to whom it is granted and his agents, employees and workmen, in all work
done in, around and upon said building, or any part thereof, shall conform in all respects to the ordinances of
Fridley, Minnesota regarding location, construction, alteration, maintenance, repair and moving of buildings
within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinanc e&
CLARENCE BELISLE Building Inspector
NOTICE.
ThIs ponait does not cover the construction, instillation for wiring, plw*ing, on heating, sewer or water. Be sure to as
the Building Inspector for separate peraft for these items.
V
APrA.MV-I.Q1 FOR '.1JILDING D.r.- L IT
To Be Used Ad
Front Depth Height cp
Sq. Ft.Cu. Ft.
Front Depth — 0 Height
Sq. Ft. Cu. Ft.
Type of Construction , /ddA4 r Estimated Cost
To Be Completed
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City of Fridley Ordinances
and rulings of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application are true and correct.
DATE D -/ 7 SIGNATURE -22,&,1"t
(Schedule of Fee Costs can be found on the Reverse Side).
x
b r
Q
Cbz OF- MME7, NINNESCTA
OWNER'S NAME '
'/ l 15 __/V . Wi"I DER
ADDRESS % il
j/ if. Brl c C C%M 6f P ADDRESS
-333
� e
IT E — 7 _ % trl
e
LOCATION or BUILUIING
N0.
STREET
PART OF LOT
LOT BLOCK ADDITION OR SUBDIVISION
A 61 V'_5
A 1J.1 F
CORNER LOT INSIDE LOT SETBACK'! o
SIDE -YARD
SEWER ELEVATION
�l _ /li . FOUNDATION ELEVATION
/6
�L2--r-
:0
's
Applicant attach
th form Two Certificates of Survey
of Lot and proposed
building locatior5drawn
on these Certificates.
DESCRIPTION OF BUILDING
To Be Used Ad
Front Depth Height cp
Sq. Ft.Cu. Ft.
Front Depth — 0 Height
Sq. Ft. Cu. Ft.
Type of Construction , /ddA4 r Estimated Cost
To Be Completed
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City of Fridley Ordinances
and rulings of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application are true and correct.
DATE D -/ 7 SIGNATURE -22,&,1"t
(Schedule of Fee Costs can be found on the Reverse Side).
x
b r
Q
City of Fridley j
. .
Application for un�b�ng and Gas Frtt�ng Pernut
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
G7
IA
;
Y
uS
Z
V1
p�U'
W
W
?
z
�O
R
N
WATER HTR.
GAS
ELEG
M
• Future Connection Openings
New Fixture, Old Openings
Connected wi3h
Sewer E]
Cesspool E]
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES: NO. RATE TOTAL
Number Fixtures ........ k x $2.00 $
Future Fixture Opening ................
New Fixture Old Opening .............
Catch Basin ...... .....................
Water Heater (Up to 99,000 BTU) ......
New Ground Run Old Bldg . ............
Electric water Heater
GAS FITTING FEES: NO.
1st 3 Fixtures ..........................
Additional Fixtures ....................
Gas Range to 199,000 BTU ..............
REPAIRS & ALTERATIONS—Refer to Code
x $1.50 $
x $3.25 $
x$3.00 $-1• OC
x $3.25 $
a $2.00 $
RATE TOTAL
x $2.00 $
x$.75 $
x $5.00 $
Dept. of Bldgs. Phone 860-3450
a
City of Fridley:
The undersigned hereby .makes application for a permit for the work herei
specified, agreeing to do all work in strict accordance with the City Ordinance
and ruling of the Department of Buildings, and hereby declares that all the fact
and representations stated in this application are true and correct.
Fridley, Minn e 197
Owner ,a / �,- �� jer
Kind of BuildingF1-� �
Used as
To be completed about > :f
Estimated Cost, ® Ca
Old—New. Building Permit No '/ Permit No.
Signed�
ROUGH D � I
FINAL
Description ................................................$
TOTAL FEE $— az
By
Business Phone No- 7 -3.2 C
PARTIAL RATE SCHEDULE
G WARM AIR: RATE TOTAL
Furnace Shell & Duct Work .....: $10.00 $
Replacement of Furnace ............................. 6.00 $
Repairs & Alterations—up to $500.00 ................. 6.00 $
Repairs & Alterations each add. $500.00 ............... 3.00 $
CK WARM AIR
Furnace Shell & Duct Work to 120,000 BTU ............ $10.00 $
each add. 60,000 BTU ....................... 3.00 $
Replacement of Furnace ............................. 6.00 $
Repairs & Alterations—up to $500.00 :................ 6.00 $
Repairs & Alterations each add. $500.00 .............. 3.00
STEAM or HOT WATER SYSTEM
Furnace Shell & lines—to 400 sq. ft. EDR Steiun .. 410.00 $
Furnace Shell & Line—to 640 sq. ft. IDR Hot Water .. 10.00 $
Each add. 200 sq. ft. EDR Steam ...................... 3.00,$
Each. add. 320 sq. ft. IDR Hot Water ..... ........ ... 3.00 $
OIL BURNER—to 3 gal. per hour ....::....... ..... 6.00 $
over 3 gal. per hour—See Fee Schedule
GAS BURNER (up to 199,000 BTU) .......::.........:...... 8.00 $
over 199,000 BTU See. Fee Schedule
GAS FITTING FEES: NO RATE TOTAL
1st 3 Fixtures —34100 $
Additional Fixtures ................. x .76 $
Gas Range to 199,000 xa`8.00 $
AM CONDVELONING
FAN BEATING SYSTEM See'Fee Schedule
VENTILATING SYSTEM
ALTERATIONS cit REPAIRS TOTAL FEE
FlNlilo /� s 2 %- Z
Dept. of B1dga. Photos 880-3490
City of Fridley:
The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in strict accordance with the City Ordinances
and ruling of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application 9,M true and correct.
Fridley, Minn^-~-°
Kind of
Used as
To be completed about
Estimated Cost, $
Id New. Building Permit No. Permit No. /
DESCRIPTION OF WORK
HEATING or POWER Hot Water, Warm Air—No
Trade Name Size No
Capacity Sq. FL E.D.R BTU H.P.
Total Connected Load Bind of Fuel
BURNER —e am Size No. ZOR AQ_
� 7/�"
.
Capacity Sq. FL E.D R- BTU .�.®Q H.F
(REMARKS-OYER)
, PRAI-M,
Wv1AW
r
Original
PERMIT for Power Plants and Heating. Cool=
ing. Ventilation. Refrigeration and Air
Conditioning Systems and Devices
DESCRIPTION OF WORK
No. of- Heating Plants to be installed—altered—repaired
Make A Size—
Oil
ize Oil fired---,- Coal fired ; Gas fired—; Gas Authorization No.
Remarks
Approved by
Final Inspection
19_
Inspector
5.=)- l g--�l
Permit N° 47 41
Fee $ ��
Office of the Inspector of Buildings
City of Fridley
City of Fridley, Minn. C;2 , 19ao
Owner
Location /19
Kind of Building! da,2
How Occupied
Work to be Commenced—, 19
To be Completed ' d ,19*90
Estimated Cost, $ ® O
Old- ew, Building Permit No.
Permission is hereby granted to ( ? s to install—erect—use the material and devices described in the
above statement. This permit is granted upon P express condition that t person to whom it is granted, and his agents, employees and workmen, in all the work
done and materials used under this permit, and in the operation of the deviceft herein mentioned shall conform in all respects to the ordinances of the City of Fridley
relating to or governing the work to be done and the operation of the devices herein named, and to the specifications setorth in the approved application for this
permit on file in the office of the Inspector of Buildings.
( I ) A) JLA��� 9- 4a=n!�=d L4-2 - Inspector of Buildings
42 2M 11-67 V
SUBJECT
PE_Rk.
City of Fridley
O 15539
AT THE TOP OF THE TWINS
BUILDING
PERMIT
P
ECEIPT NOr. .
`L _____ COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
"1 CITY HALL FRIDLEY 55432
NUMBERREV.
DATE
PAGE OF
APPROVED BY
".j 612-571-3450
910-F15
110/29/79
JOB ADDRESS 119 Rickard Road
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
2
1
Garten's Addition
SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
David Olson 119 Rickard Road
571-5142
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO.
owner
4 ARCHITECT OR DESIGNER MAIL ADDRESS
ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS
ZIP PHONE LICENSE NO.
6 USE OF BUILDING
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION IX REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Finishing basement
9 CHANGE OF USE FROM TO
STIPULATIONS
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCYLOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SQ. FT.
CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 DAYS, OR IF CONSTRUCTION
R-1
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED.
NO. DWLG. UNITS
OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
VALUATION
SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$5,000
$2,50
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$30.00
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION.
d
PLAN CHECK FEE
TOTALFEE
$ 7.50
$40.00
)G ATUREOFCO)R T OWK-UTH DAGENT (DATE)
EN PRO
R AID ED.THIS IS YOUR PERMIT
�� ��
- giGNATU
r BLDG INSP
� TE �-
OF OWN R(IF OWNER BUILDER) (DATE)�+
CITY OF FRIDLEY'
APPLICATION FOR RESIDENTIAL BUILDING PERMITS
(New, Alterations, Additions, or Repairs)
OWNER:
ADDRESS:
TEL NO: �� l - .S—/ 46 n
BUILDER: - � cv kj e
ADDRESS:
TEL NO:
Construction Location
STREET NO: q STREET: Z j` L / ,, "i „A2 14
LOT: BLOCK: ADDITION: GA ✓ �c> N fS CL
Corner Lot: Inside Lot: L Setback: Sideyards:
Applicant attach to this form two Certificates of Survey of lot and
proposed building location drawn on certificates to scale.
DESCRIPTION OF CONSTRUCTION
Front: Depth: Height:
Square. Feet: Cubic Feet:
base tm e ✓lt
Front -
Depth : Height:
r
Square - Feet: Cubic Feet:
Type of Construction: W a o� -�v ct w. Q Estimated Cost: $
To Be Completed:
Alt. A Alt. B
Proposed Driveway Width If New Opening Is Desired: $ $
SEE REVERSE SIDE OF SHEET -
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City of Fridley Ordinances and
rulings of the Department of Buildings, and hereby declares that all the facts and
representations stated in this application are -true and correct.
DATE: 10 �? SIGNATURE:
Stipulations:
,MC'Sr( 30.00
pit
ITy fa.d
CITY OF FRIDLEY
APPLICATION FOR PLUMBING AND GAS FITTING PER41T
PARTIAL RATE SCHEDULE
RIND OF BUILDING
en
USED AS
RATE
>,
H
$3.00
Future Fixture Opening
x
v
New Fixture, Old Opening
X
d
Catch Basin
Water
$5.00
Water Heater - to 99,000 BTU
x
$5.00
m
x
$10.00
Water Softener
m
$7.00
q
m
w
w
tp
$5.00
Heater
lst 3 fixtures
x
°a
Additional Fixtures
x
$1.00
Gas Range to 199,000 BTU
x
$3;0.00
REPAIRS & ALTERATIONS
a
First $100.00
.$5.00
each add. $100.00 or fraction
n
G
e
rc
8
0.2
ci
m
4j
rs.moi
H
a
q
.�
b
M O
.°e
.�
ro
X ro
m
m
y
lec
to
U
a
r
go3
o w
m
w
tai w
a 3
t
t�
o
as
1st
2nd
3rd
4th
I
L
(R) a Future Connection Opening
Connected with Sewer
M - New Fixture, Old Opening
Water
PARTIAL RATE SCHEDULE
RIND OF BUILDING
PLUMBING FIXTURE RATES: NO.
USED AS
RATE
Amber Fixtures
x
$3.00
Future Fixture Opening
x
$2.00
New Fixture, Old Opening
x
$2.00
Catch Basin
x
$5.00
Water Heater - to 99,000 BTU
x
$5.00
100,000 BTU to 199,000 BTU
x
$10.00
Water Softener
x
$7.00
New Ground Run Old BuildiuQ
x
$5.00
Electric Water Heater
x
$5.00
GAS FITTING FEES:
lst 3 fixtures
x
$3.00
Additional Fixtures
x
$1.00
Gas Range to 199,000 BTU
x
$3;0.00
REPAIRS & ALTERATIONS
First $100.00
.$5.00
each add. $100.00 or fraction
$2.00
State Surcharge
TOTAL FEE
REINSPECTION FEE
x$10.00)
TOTAL
$ ®0
Job Address41.2
Department of Buildings
City of Fridley
Tel. #571-3450
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the City Codes
and rulings of the Department of Buildings, and hereby declares that all
the facts and roprosontations statod in this application aro truo and ccrrect
Fridley. Mn. ,,� % 19
OWNER ,-J C�G/✓C_ ��(/
RIND OF BUILDING
USED AS
TO BE COMPLETED ABOUT
ESTIMATEDCOST
OLD - NEW BUILDING PERMIT NO.
PERMIT NO..
CompanyIr
Signed By
Tel. NO.
ROUGH INSP.
-
' Data
FINAL INSP. 4 t
$ Date
$
$ APPROVAL FOR PERMIT
$ MINIMUM FEE FOR ANY PL". ING PERMIT IS $7.50 pLUS $.50 STATE SURCHARGE
$ .50
$ X72
CITY OF FRIDLL-Y IN6FL(_ I iUN UIV.
6431 U°hiversity Ave NE
eridley, MN 55432
(763) 572-3604
APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
MARK NUMBER OF FIXTURES TO BE INSTALLED ON EACH FLOnR
Lttective Un Jan 1, 2uO2
PLUMBING FIXTURE RATES
New Fixtures
Old Opening, New Fixture
Beer Dispenser
Blow Off Basin
Catch Basin
Rain Water Leader
Sump/Receiving Tank
Water Treating Appliance
Water Heater -Electric
Water Heater - Gas**
Gas Range**
Gas Dryer**
Back Flow Preventer Required ( )Yes () Nc
Type
Reinspection Fee $47.00/Hr
NO. RATE
$ 7.00
$ 4.00
$ 5.00
$ 7.00
$ 7.00
$ 7.00
$ 7.00
$10.00
$ 7.00
$10.00
$10.00
$10.00
$15.00
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.5% of Value of Fixture or Appliance
State Surcharge
TOTAL FEE
TOTAL JOB ADDRESS
The undersigned hereby makes application for a permit for the work herein
specified agreeing to do all work in strict accordance with the city codes
and rulings of the Building Division, and hereby declares that all the facts
and representations stated in this application are true and correct.
20
OwnerY2n�rV
Building Used As��'�'�
Estimated Cost PERMIT NO.
50
$V�
PLUMBING COMPANYY�L)�-��L
SIGNED BY/ //� TEL N0
6it 24
FAX # S— _
1�1'
Approved By Rough -In Date Final Datr b_ -;
"COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6-A.
ly
SU
COMMON VENT INFO ON BACK SIDE
THE BELOW MUST BE FILLED IN WHEN REPLACING FUEL BURNING APPLLANCES OR THE
APPLICATION WILL BE RETURNED
COMMON VFNTr VENT CY)NN C`TQR ANn C`C MR1 IRTIQN AIR VFRIFI AT1C)N
When re la ring an existing_fi ,rant -s%, the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and firestopped where required. YeNo ( )
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications including sizing, length, number of elbows and termination. Yes�No ( )
The undersigned also verges that the replacement unit is a listed assembly
and meets the current codes and manufacturer's specifications. This does
include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances.
Yesj(,� No ( )
The existing rombustion air is sized and installed to meet the current codes
and manufacturer's specifications.
Yes No ( )
When required to install a new cambi ,scion air it will be sized and installed
to meet the current codes and manufacturer's specifications.
Yes,/No ( )
When installing a new ventingyys em, the undersigned hereby verifies that
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does include AGA-GAMA Category I Central Furnace
Venting Tables for fan assisted and natural draft appliances.
Yes No ( )
Is the common vent and vent connectors sized and installed correctly after
an appliance has been removed from the common vent and vented
separately as per current codes.
Yes o
Appliance Tyne and Rize/Common Vent and Vant rnnnPetorVan
( )
Informa ion
Appliance #1 Type _
Appliance #2 Type _
Appliance #3 Type _
Total Appliances
_ BTU Input
_ BTU Input
_ BTU Input
Total Btu Input
Fan Assisted or Nat
Fan Assisted or Nat
Fan Assisted or Nat
Common Vent Type Vent Height Diameter inches
Appliance #1 Vent Connector Height ft Length ft Diameter in Type
Appliance #2 Vent Connector Height ft Length ft Diameter in Type
Appliance #3 Vent Connector Height ft Length ft Diameter in Type
HEATING CO:
Signed By:
Date :
4F
CIIYOF
FRIDLEY
FRIDLEY MUNICIPAL CENTER • 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 • (763) 571-3450 • FAX (763) 571-1287
June 22, 2004
Ms. Mary Jane Olson
119 Rickard Road NE
Fridley, MN 55432
Re: Final Inspection at 119 Rickard Road NE
Contractor: Northwoods Mechanical
Dear Ms. Olson:
A plumbing permit was issued on January 29, 2003 to install a gas water heater at your address.
On February 25, 2003 a final inspection noted that the following correction needed to be
completed before the permit could be finaled;
Provide combustion air per manufacturer's instructions and UMC Section 602.
The reinspection has not been requested as of this date. The permit fee that was paid covers the
inspection to make sure the work was completed according to the Codes. We will keep your
permit open for another 30 days and if we do not hear from you within this time to set up the
inspections, we will mark the permit "no inspection called for by homeowner after notification"
and the permit will be expired.
To set up the inspection or to have any questions answered, please contact the Building
Inspection Division at (763) 572-3604.
Sincerely,
DJ/mh
Building
PLUMBING
Permit No.: H)[)55&
Inspections
RESIDENTIAL APPLICATION
Received By:
604
73604
763-572-3
CI'T'Y OF FRIDL]EY
Dat �
763-502-4977 FAX
EFFECTIVE 1-1-08
_
DATE YOUR E-MAIL ADDRESS U/li tie
SITE ADDRESS ¢ ► �+✓
THIS APPLICANT IS: ❑ OWNER `4 CONTRACTOR
PROPERTY
�,(�e Q
NAME:t&l
OWNER/
a►CITY 'C STATETENANT
ADDR1
-71 _ S l�ZPHONE
CONTRACTOR
NAME:
SUBMIT A COPY OF
STATE LICENSE # EXP DATE Ct
YOUR STATE
LICENSE, BOND AND
STATE BOND//# em D S/ �% EXP DATE %
CERTIFICATE OF
ADDRESS: l E%6 9 J 7! L. sc% CITY g!!�)%S C ® STATEZIl'557.3
INSURANCE
PHOI6LZ -- GJ —S 3 FAX
PERMIT TYPE
_�STNGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK:
NEW ❑ REPLACEMENT
DETAILFrDE CRIPTION OF ORK Gr C UlJ n � Gly' a G T ^SIFG�
�
PER MS 1613.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whichever is greater, for the
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor )
Labor cost under $300 = $15.00. Labor cost between $300 to $500 = cost of labor x .05 = plus .50 surcharge
OR
FOR PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL
NUMBER OF EACH BELOW). MINIMUM FEE $15.50.
BATH SINK/LAV DRAINS —WATER PIPING
_ _FLOOR —SHOWER
BATHTUB _ GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
_
CLOTHES WASHER KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
--CLOTHES
_ _ _
DISHWASHER LAUNDRY TRAY _WATER HEATER ($35) FOR IRRIGATION
_
WATER METER _ OTHER
<.,.Fye..,.
fs.. "
Permit Fee $
Number of fixtures @ $10.00 x $10.00 = $
Surcharge .50
Number of fixtures @ $15.00 x $15.00 = $
OR Number of fixtures @ $35.00 x $35.00 = $
TOTAL DUE $
State Surcharge = $ .50
(MINIMUM $15.50)
(MINIMUM $15.50) Total = $
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c4se of all work whic qui es review and approval of plans. Q
e
SIGNATURE OF APPLICANT � PRINT NAME/G7Z`J�' � 1 DATi< T 2
APPROVED BY DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977