P - 42245�U11C�lllg �, � ��19����;1.�� Permit No.:�� ���
Inspe�tions ������'�`��� ���������(�� Received By: �,
763-572-3604 ���� ��+, ����.+�� � � cl�i�J� �, ' ����
763-502-4977 FA� EFFECTIVE 7-I-20i0
DATE !� '" �I- ( D YOUR E-MA.IL ADDRESS
SITE ADDRE3S '� � ` f � `'� � 1Q '�•. N �`
THIS APPLICANT IS: O OWNER �CONTRACTOR
PROPERT�'
OWNER/
TENANT
corrTx�cTOR
SUBMIT A COPY OP
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
Tes lc<.-,�
PHONE: % f 3� S�% �- i C 3�i
COMPANY NAME: YG� � � „
CONTACT PERSON: (n J � •
STA'I'E LICENSE #
� CI
.��� o-
�
EXP DATE
�vo_.�_ �Id� STATENr+ZIPSSV31.
aDD�ss:,�a 9 o r--1 ��� .s� o..� � crr}r ��� �p t�_STATE�' �! ZIP ss�a l.
rxor� '7 � 3 � S� 1� 5 9 F.�
TYPE OF WORK: I � �W
FAMILY ❑ TWO FAMILY
�EPLAGEMENT
� TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIl'TION OF WORK Z11s��a I( 12,OI����-�. ..�� t' lr- �N A!� �- �„� � Ce�cL��-� k,�►��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WI�RE NOTED. FIICTURES: (INDICATE TOTAL NUMBER OF EACH BELOW).
PROVIllE HEAT LOSS CALC'S PER MANUAL J 2006 ASIiRAE AANDBOOK.
Equipment Installed MFG: � v v� MOAEL: 12G IQ-G - � 6 SIZEJBTU �
IvIFG: ✓� V K� MODEL: U 11 P i°� D a-� SIZEBTU �✓,�
MFG: MODEL: SiZE/STU
1 A/C $25.00 _FIItEPLACE (GAS) $15.00 _GAS RANGFJOVEN $10.00
AIIt TO AIR EXCHANGEER $15 FIltEPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOII,ER $35.00 �FURNACE $35.00 GAS UNTT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 _PQOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 _VENTII.,ATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALIA UNTIL PROCESSED
� 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 I understand this is
not a permit but only an application for a permit and work is not to start without a permit; that the worlc will be in accordance with the
approved plan in the case of all worlc which requires review and approval of plans.
SIGNATURE GF APPLICANT ��'►- /' � � �✓ PRINT NAML- �� ✓' S f �.r �OT_DATE D " �� � � �
AL II�ISPECTORS SIGNATURE
�.
DATE
�a� �� �r:c��e�v
8�3����� ��n��r���ac�ns ���ar#���a�
��� 1 University !�venue �, Fridley, iV.IN �5��?
'�63-572-3b�� F��: 763-�02-4977