P - 42120Buildin�
Iilspectiol�s
763-�72-36�U4
763-�02-4977 FAX
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EFFECTIVE 7-1-2010
Pernzit No.:
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DATE r Q- Y- � � ' YOURE-MAIL ADDRESS
SITE ADDR�SS ��� �O � ✓+C�- � N C �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERT'I'
�Oj�VNER�
T NA�T
CONTRACTOR
SUBIVII'I' A COPY OF
YOUR STATE
LICENSE WITH
� �PPLICATION
ADDRE$S: � io Z o�% O p✓10f. Ll�- • N� CITY �'� ' STATE N� ZIP�
PHONE: 7 x� S�T ri' 'I S��
COMPANY NAME:_
CONTACT PERSON:
� Lt�
STATE LICEN�iSE # EXP DATE
ADDRESS: (J�o�-Q � � �--t r C�. IN� CITY F1Q l d� ti. STATE H�ZIp 5,��,
PHONE � b3 �'1 S� pL� 7�J FAX
PE1tMIT TYPE ��GLE FAMILY C7 TWO FAMILY
TYPE OF WORK: � �' ��PLACEMEx'r
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIICTURES: (INDICATE TOTAL NiTMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANU J 2AIs ` 006 A�SHRAE HANDBOOK
Equipment Installed MFG: ✓� v MODEL: ►'�G iJ ►V � p�7 SIZEBTLT � 6 d 4
MFG: MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
,P.IR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
_BOILER $35.00 �FURNACE $35.00
�CHIMNEY LINER $10.00 GAS DRYER $10.00
DUCT WORK $10.00 _GAS PIPING $] 0.00
SIZFJBTU
SIZEBTU
_GAS RANGElOVEN $10.00
NEW GAS GRILL $l 0.00
_GAS UNITHTR $10.00
_POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION 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 1 understand this is
not a permit but only an application for a permit and worlc is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work which requires review and approval of plans. �
SIGNATURE OF APPLICANT �.. L_A .. =.
APPROV
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TURE
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�uilding Inspec�ions �epar�ment
64� 1 University Avenue NE, Fridley, MN »�32
763-572-3604 FAX: 763-�02-4977
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