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Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTNE t-1-2011
�aTE .:•' r � �' ' � � vovR E-�L fwD�ss i f �c•� � {� S �i � �
SITE ADDRESS �°I �� a V� S 1 �''� �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
❑ OWNER �ONTRACTOR
reriiu� i��.: /��+��-��5��
Received By:, l � N
Date I��21� � � �.� x� � � � �
NAME:�L� � C� /�t t'�t.� ✓� '.�"` .i- h V e S �I�-� .n �. � 1'ii...� �/"
ADDRESS: '�J 9�.,� � f}t^!� 1-�%� �1 �"�lJ' CITY� �h(I.i��iv.� ��- STATF�i�ZIP 55 ���
PHONE: � r � ' a"U.7 — �O %7 L`�
COMPANY NAME: �e/`p�(`t S�i►ti 1'� �i' (
CONTACT PERSON: �iti y
�ev+i �Ser�u�s
STATE LICENSE # EXP DATE
aDD�ss: �o=}z% L2-� -�vr4�� �1.! L CITY b s`�.e � sTATEr��L'zlP 5'�G
PHONE G� ( �- " �s+S � ` 4l/ C � FAX
TYPE OF WORK: �� NEW
FAMILY ❑ TWO FAMILY
�EPLACEMENT
DETA�,i„F�� DESCRIPTION OF WORK ;�i.. S•fi� 1
�tl�i� d�. ,,.n m�,,��� A,,, d_.,�,��.,. ,
❑ TOWNHOUSE
❑ ALTERATIONlREMODEL
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: V q��. �y r.c MODEL: �S '' L5 £���� SIZEIBTU �� �"C�:
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35A0
BOILER $35.00 ✓'FURNACE $35.00
CHIMNEY LTNER $] 0.00 GAS DRYER $10.00
DUCT WORK $10.00 GAS PIPING $10.00
Number of fixtures @ $10.00 x $10.00 = $
Number of fixtures @ $15.00
Number of fixtures @ $25.00
x$15.00=$
x $25.00 = $
Number of fixtures @ $35.00 � x $35.00 = $ ��) ~
State Surcharge =
FEE
$ 5.00
SIZE/BTU
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS LJNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
Tota1= $ ��( U'
THIS 1S AN APPLICA'I'ION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building 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 an wark is not to start without a permit; that t work will be in accordance with the
approved plan in the case of all work which review and approval of plans.
�� A �y
SIGNATURE OF APPLICANT PRINT NAME C� �! DATE %J '�L'� '��
APPROVALINSPECTORSS ATURE DATE
PLEASE NOTE: SEPARATE PERMiTS ARE REQUIRED FOR BUILDING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977