P - 48238Building
Inspections
763-572-36U4
763-�02-4977 rAX
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���������� !�.������.����,"� Received B}�:
���� �� ������T Data Rec'df� ��j
EFFbCTN� 7-1-2010 � �
DATE j p� � / l- L I YOUR E-MAIL ADDRESS
SITE ADDR�SS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
�PPLICATION
PERMTT TYPE
TYPE OF WORK:
❑ OWNLP. �ICONTRt1CTOR
NAME: .�.J,41J �t1 FC �,.,�A_r G
ADDRLSS: .�1 A I �31 �" A V t,. W� CITY �IQ,t � �. ' STATLM� ZIP ,ss �1�.(
PHONE: 763�s��� `Igd�
COMPANY NAME:_
CONTACTPERSON:
STATE LIC�NSE # EXP DATE
ADDRESS: n a-� � � 0.-�ti � N� CITY �� ��OIL STATEMv ZI�� �� 1'
PfIONE ��� '1S4 �l�t q FAX
LFJ SINGLE FAMILY ❑ TWO FAMILY
❑ NEW � REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
C�
FEES ARE BASED ON $50.00 PER FIXT'URE, EXCEPT WHERE NOTED. F'IXTURES: (INDICATE TOTAL NUNIBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUA J 2T,� V V�ASHRAE HANDBOOK
Equipment Installed MFG: lC. MODEL: 12 �(�+ C ����'� k'� SIZE/BTU � 0� o u
MFG: MODEL: SIZEBTU
�G; MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 =FURNACE $35.00 _GAS UNIT HTR $10.00
CHIMNEY LINER $]0.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 _VENTILATOR 575.00
ar..�.....t�.,...,..F�.;%,�:;�a� fl"�1l1 f1f1 :�.. v�`�C7'lV�(1(l�_ �`-.:� . . . . . . . . .. ..
���Numbee oifixtures-@ $15.00 �` x� $1'S.�O = $��;
Number�offixtures�@ $�25_00 ��� x$2:S.D0"= $'
Number of fixtures ,@ $35..00 6� x $35.00 = �` ��• ° �
S4ate Surcharge = $ SAO
'lNTTNTMTTM•FFF: '�4b:0111 Tntal =$ 4 b� b�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROC�SSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accur�te; that the worlc will be in
conformance with the ordinances and codes of the City of Fridley and with tl�e Iviinnesota Construction Codes; that f understand this is
uot a permit but only an application %r a permit 2nd worlc is not to starr without a peimit: tllat the worlc will be in accordance with the
approved plan in the case of all worl<whicti requires review andpa�proval ofplans.
SIGNATURE OF APPLICANT ���1� � C� /' '�'RIi�,T�ME �� r� `� � G-A f� DATL- �,-� a�` C I.
APPROVAL INSPECTORS SIGNATUREr
PLE:�SE NOTE: SEPAFtAT�
s,� ` . �i-- �
DATL
ERNIIT ARE �QIJIRED FORI3tJILDING; ELECTRIC�L �ND MLC NTCA
, �itg� fl�' �a-ac�ley
�uilaing ins�ee�ions �e��ir*�nen�
6431 Universih� Aventie NE. Fridley, MN »��2
763-�72-3604 PAY: 763-�02-�977