P - 43893�uilding 14�����N����
Inspections �����i'l��'�,�.�, �.���,������1'�I
763-�72-�6U4 ���� ��' � . ���
763-502-4977 rAX EFFECTNE7-1-2070
DATE / L` S-' �� YOURE-MAIL ADDRESS
SITE ADDR�SS �
THIS APPLICANT IS: ❑ OWNEP. �SCONTRACTOR
PROPERT'Y
OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE
LICENSE WITH
� .�PPLICATION
PERMIT TYPE
�rE oF woRx:
Permit No.;J� ( �n �-('1
Received B}�:l U 1V`�''
��
D ;�� � �
NAME: �'�1�A 1"t t� �c+ �. � 6 �4 r� � C, h
ADDRESS: S��g ��' � �� CIT ��12t+��`a ' STAT'E�NZIP SS'�3Z,
PHONE: C�a�.3 � � ��'� a�il �O �
COMPANYNAME: rc�
CONTACT PERSON: �, +' �`�
STATE LICENSE # EXP DATE
ADDRESS: �� b�I A-��. "-'E 1�,Ct CITY FY2�bl.�_STATE;1-_�ZIPy�,�
PHONE '� 6J� �'S �'I a � � � FAX
PI SINGLE FAMILY ❑ TWO FAMILY
❑ NEW e�REPLACEMENT
DETAILED DESCRIPTION OF
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
� . r, . ,..E- L�� ..�z .� e.�. � ,a � 1L..
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIICTUREB: (INDICATE TOTAL NIIMBER OF EACH BELOV�
PROVIDE HEAT L03S CALC'S PER MANU J 2006 ASHRAE HANDBOOK.
EquipmentInstalled a'� MFG: �AyV1ti MODEL: I�C�Y�1"iAAv��a� � � SIZE/BTU �% �_ ,�
A c MFG: A�n ti MODEL: Y� �F � V SIZEIB�EJ oZ I � h
MFG: MODEL: SIZEBTU
�A/C $25.00 _FIILEPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIR TO AIIt EXCHANGEER $ I S _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 �FURNACE $35.00 _GAS UNIT IiTR $10.00
CHIMNEY LiNER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 _GAS PIPING $] 0.00_ VENTILATOR $15.00 �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buildin� permit and I aclrnowledge that the information above is complete and accurate; that the worlc 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 and work is not to start without a permit; tl�at the worl< will be in accordance with the
approved plan in the case of all worl< which requires review and proval f plans.
SIGNATURE OF APPLICANT ���� PRINT AME C^1•� f� \�O l7 (J DATE v" s" 1
APPROVAL INSPECTORS SIGNATURE DATE l%
PLEA�E N:OTE_ SEPl�RAT'E PERMIT`S 'RE REQUIRED. FO"R BtJILDING, ELECTRIC:4L AM311�tEC `. NICA OFtK.
1 City of �+a-adley
�uilcding Inspec+�ions �epar�ment
6431 University Avenue NE, Fridley, MN ��432
763-572-3604 FAX: 763-�02-4977