P - 42732Frorn: City of Fridley To: ?63434b46�} Page: 2!3 pate: 2/2/2009 9:28:43 AI��
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�r��;���;�zlc�zis ��;SIDEN�I,IAL APi'LI�ATIaN R�cei�edBy. � �'�
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� CITY (��' FRI�LEY ��t���; 10
;j�i �-5t72-49?7 Fr� r:r�r•�cT�vr: �-i-ci�
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j�� L�=�it __Au�ust 2, 2010 You�i�:-nn,a�LAU��zr�s
<:r�t �i»�z�.:,�____4555 _3rd St, NE
�j !�l lh ,�P1'Lt�':�,N I� 1J: ❑ (�lNN�li �7C-C7NTIZ.SCTC)IZ --
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±� ��Z`�»'Y-��r�` �.<qmr.:__ Gordon Peterson
t?�'v��v'r;i�;' avv�i�:;s 4 5 5 5 3 r d S t. N E `��T�- Fr i d 1 e y sT,aT� MN �ir� S 5 4 3 2
� '��r'`'����`�' S72-1525 —
ti PHC)NE:
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i�t)N'�'it�.C'I'OtZ ���NinAti�v N,��,,i�: Anderson Burner Service, Inc .
�Nc'`E= Howard or Di
� l ]'Al�, IL t.'1"I'1' �'ONTAC'"f Pt.1L�(lN:
� �t�i.n��t � ;x� -� 2=� 9- � 9
� sr,�Tt; LlcErvs� r 5 5 2�fl �R � nF U,�Tt
a i>_,.���.�,iir�i> i <.»z c�,�.s
� ��ui��t�'ac. �Lr��zh�5: 17535 Chisholm St. NE cir�' Ham Lak . �TAT�,�___�tn�_�.�II_4_ 3
� ,�.<<�.i��rcr�> >� c��� �3t�NO ;,NOr:� 763-/�34-6464 �ax � same
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i'Y�IZV'l��l' �I�Y�PI: �INGL� hAl�1lLl' ❑ T41'O h'AM1Ll' O TO1�'NHOUS�:
� 9'4 �'1^: OY+ 1�r(}1ZCi' � N�:W �❑ Jt�,PLACE141ENT � ALTk.RATInNlItENi011�,L
L)TiT'��ILf�ll DESCR[FT10N OF \�ORK _ r e 1 a c e o i 1 f � r n � P
PLl2 1��iS lf>B.bfi� thc ��crnzit f�c is � minimum of $15.00 or 5'%u of the total cost up to $500.00, whichcvcr is gn;atc;r, for thc
i�n��rt��caiicnt, installation or rcplacc;mont of a residcntial fi�turc, cxcludin� thc fxturc;s. (This should reflcct onty thc cost of labor )
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Labcyr cost undra• �3UU =$15.UU. Labor catt bctwccn $3U0 to $SOU = cost of labor x.OS =
l�()!i ritq.ir:crS �vH�Kk: LABOR L-'YC��US $SOU; N��S AR�: BASEll ON $10.01) A�R FtXTU]Z�., �C�:PT WH�R� NOT�ll. NIXTURES: (WDICAT�.TOTAL
!`Utilk3k:1�01� I:AC;N t3�:LON'1 .
t:c�uipnicnt]nstalled 141}%GW�-�11SII1S011 n�oU��: CHB105 s�.�,'gTU 105,�0�
ti1NG: M011�:L: SI'LF�IBTU
M l^G ; M011 �:L: S 1"L�.1 BTU
�-C: $2S.i1t� _F1R�PLAC� (GAS) $15.1)() GAS ]iANGh:fOV�N $l�AU
_ -�1R"CO.411ZL-XCHANGEb1Z;�1S F1126PLACE(W�OU)$35.0(i NE1�'GASGRILL$10.00
li(71LL1L'�35.U0 �NUKNAC�:�35.00 G;�S UNIT HTR$IQ.QO
CllllwfNtr:l' LINEIZ$ IO.i)iJ GAS L)IZYER $I0.00 �I'nOL HE�TEIt $35.00
UUC'r Vd(�RK:� I(1.00 GAS PIPING $10.00 V�NTILAT�R $15.00
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�'f-[Zt�4�i t��s� �'�.i�.��c.,1'� ���.,�I�u��.R::�Si�u .<: � .....;; . , .. .::. . ..:: :. .:;.;,. . .. ., , F��iTF�� �€3�:�*�.�EF:>'l.� ��_E[t, ����#=:
Pcirriitt�cc `�� � _.__ Numbcrc�ffixtures{2$�0.p0 x$lU.UO=�
Slil�r�argc S°'�$ � Number uf fixtures {a $15.OU x$15.UU =$
"i'O"CAL DUE $�.�� � �� OR Numbcr of fixtures (,� �25.UU x$?S.UU =$
` I/ � Nun�bcr af fixtures L� $35.U0 x�35.QQ =$
�� ��� Statc Surchargc = $ .50
MIri1141U _._ 14111�TIMUM $15.50 Total = $
THIS lS aN APPLICATInN h'nRA PEItIvt1T-NOT VALIll UNTIL PRCK'�;SSEll
t h;:reby appty tirr x mectunical pennir ar�d 1 acknott�ledge that the inforn�ation ahove is cooiplere and accurate; that the work will be in confortnance with the ordinances
' and �+ndr., oY' che City of Nridley and w•ith fhe . -tnictinn C understand this is not a pemiit but only an application for a pennit and work is not to
,i��rr r; ithour a pennir, that the work c' e in accordance tvith i lan '� the case ofall work which requires review and approval of plans.
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StGNA"C'l!RE OF APPLICA T _ PRINT NAME _DATE 1���
:�PPI<Q\`�D �3Y _ DATE
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i�i..r���:�� �a°c� .. ����rr� ���iT� ��.�.�.� :r.��z�::�c��::sut�.���rc�, �c�����:z�:��.�.�:c����r�.�€��,� v��t�. >;<
Citv oi Fridlev
Buil+�ing laspe�;tions Department
fi431 Univcrsity Avcnuc NE, Fridlcy, MN 5�432
753-572-35()4 FAX: 763-502-�977
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