P - 42277Building
Inspections
763-572-3604
763-502-49 7 F
DATE C�
SITE ADDRESS
'THIS P.PPLICANT IS_
PROPERTY N �:
OR'NER/ aDDt�;
TENANT
�orrE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTT4E 2-L9-09
E-MAlI,
❑ O�iNER
C0�1P.=1NY N.�1E. •��c+� wai �� �caw �y v� r.�� .. ....... ..... ..
CONT�CT PERSON: y
STATE LICENSE l� F17 1R7d_7�fi� DATE
ADDRESS:
PHONE
FAI�IILl" ❑ T�1�0 F.4A�III,1'
❑ NE��' �REPLACEh�NT
DETAILED DESCRIPTION OF WORK
----- - --�-..
Per►nit No.�%-�IL" '� �� I 1
Recei� ed By.j �
n���-�� � 1
CITY STATE ZIP
FAX
❑ TOWNHOUSE
O AL,TERATION/REMODEL
U i�/l�co / /1, G�
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NiJMBIIt OF EACH BELOVI�
Equipmait Inatalled MFG: MODEL: S�ZE/BTU
MFG: �+'V� MODEL: ( SIZFIBTU J `�' �/V
��I MFG: MODEL: SiZFJBTU e�'�C `� 1
,�t�c $25.00 ACE (GAS) $15.00 GAS RANGB/OVEN 510.00
AIIi TO AIR EXCHANGEFR S15 FI PLACE (WOOD) 535.00 NEW GAS GRII.L 510.00
BOII ER 535.00 �FURNACE 535.00 GAS IJNTf HTR 510.00
CI�IIdEY LINER 510.00 _GAS DRYFR 510.00 POOL HEATER 535.00
DUCT WORK 510.00 GAS PIPING 510.00 VENTII.ATOR 515.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID tJNTfi, PROCESSED
I hereby appl_y� for a building perniit and I ackno��%le e ti�at the information above is complete and accurate; that the ���ork ���ill be in
conformance �vith the ordin es d codes of th � of Fridley and ��.ith the Minuesota Constructiou Codes; that I understand this is
not a perniit but only an plica �o f permi nd ork is not to start �vith t a perniit; that the wo � ��rill be in acco ance �cith the
approved plan in the c 'ch re � es view and approval of p s. �
SIGNATiJRE OF APPLIC PRIN�[' N.�h�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977