P - 47304,.... �� ,,,�,,,,,�, , u �„ Frorn: 763 444 8925 Page: 2/7 Date: 11/22/2011 11:07:08 AM
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�uilding �VIECHANICAL
P�ermi2 NQ.: � �
Inspectio�s R��,I��NTI�4.L APPLICAT
7�3 572-36Q4 I(�'� Receivec3 $y
�6�-so2-4g�� F�x �ITY QF FRIDLEY o����:N� V��
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oaTF � � :'Li . t 1
Si'CG ADDRESg !• -• � YOCR E-MAIL ADDRGSS
'ii iIS AI�PLICANT 15: � CI OtU7+7L-R �
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TEfYANT naDRF'ss; " � `�'�'1 � Ci7'Y �
PE ION�: STATE�� i�[F
�C1\TRACTOR CfJNiPANY tVAME: ,�i��, .
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SUBMIT A CpPY OF CON'e'neT PERS�h. _C�}- `lA.i1.}'�G`yI
YOUR STA1'E STATE LICEN5E H
LtCEtiSE WITH �p�FSS. �,;�i�(, („�.,J , � �A� �!
APPI,ICRTIQN '�'�`� �;'�'' CITY ` �i'" S1'A�+v7,11��
PH�NE��}�a�L) ,�j�i"� �j2s.l-f'l�l.i- •Qt� �C'�
FA X
PERMIT TYl'E
T1'PE QF WORK:
FAMILY C]7'WOFAMII,'Y
L1 NEW O RCPLACEMENI' Or'ALT�RA7'(01�fREMql�EL
DETAILED DESCRIFTCpN Op }�rORK��
_.. ...._
FEES 1RE A�+lSED Olti �10.00 PER TI.�7'llRE, EXCEPT VVI�;RE NOTED. � -.. -_.�
PRUVIDC HEAT LOSS C,e,LC'S PE[L MA Vl,� �TURES. ([NDICATE TOT.4L ;sT(JMRER dF E�CF[ SELdt�
Equi�+men! insrstled AL J 2006 e1.SI1Rq� }�NDBOOK.
11�iFG: �` MODCC:
S12E/STU
_A1C $25:11p
_A1R TO A[R EXCHANG� ��g
_E30ELER $35.00
CHIMNEY LiNI-�t �lO.OQ
�DUCT i�'ORK $1Q.00
Number of 6xhirra t1 Ce n nn
�tiwnber offiactures �a, $IS.QO
MF[;: �_ MODEL:
---------._
lvtFG: �i h10DEL:
�EIriEPi.ACE(GAS)525.(1p —'-'
FIREPLACE (WCx7I'j) $35.pp
f URNAC� $35.00
��AS 17�Y�R $] O:UO
x$t0.U0=$
x $ I5.00 = $
Number of fixttues @ $25.04 x $25.00 — $
--,_
Nuntber vf fixtures (a� �35.0� x $35.{}0 = $
State Surcharge =
d
� 5.4Q
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f l.�-
SIZF.�BTlI
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Si2F1i3FU
_GAS RANGElOVEN aip.p�
,�iEW GAS G81L,L $IU;fjp
GAS qh t'i' H'C3t $10,a7
__._PO{7E. HEA7'CR 535.40
�V[7JI'iLATflR �i5.00
TF31S iS.hN APPLIC.4TfON FOR,� PTRMIT-NUT VALID i)NT7L PRp�;ESS�
[ hereby appiy for a building permtt ana ( acknowledge that the ittforrnaiion above is complete �d a�curate; that the work will b� in
coafarmance with the ordinances and codes of the Gity of Fridiey ar�d w�th t�e i�qinnesota Cor►structian �cKles; t}��t T���d �� �
not a permit beet on3y an application for a permit anc! work is not to start without a
approvEd pian in the case of all work wh��`c�� u��s review and approvat of plans. ����' �at the work tivi11' 6e in accordance wiEh the
S1GIVATUttE UF APPLICA*IT :'>y.�'� PRtNT NAME� Gu�� ��� � IL`f� ` j
APP1tOVALI]VSPECFQRSS1GAIATURF. DATE t 1 '7i� ` � �
City of Fridley
Building �aspcctians Uepartrnent
6431 University ,4ven�e �r1E, Fridley, MI�f 5�4�2
?6s-572-a604 FAX; 7G3-502-497?
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