P - 42155Building
Inspections
763-572-3604
763-502-49i7 FAX
DATE
SITE qpDRESS _��
THIS APPLICANT iS:
owNEiv
TENANT
MECHANICAL 1'ermit No. �
RESIDE1�1T7'IAL APPLICATION Received By: .� '`� : i
CI'�''Y OF FRIDLEY a���►¢���-+�—�
EFFECTIVE I-1-201[
YOUR&MA[LADDR6$g�i Q( ,p����L�, � R� � `�����
, Vlr�r A !F
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--•."...•.••••• COMPANYNAME:
SUBTvIlT A COPY OF COxfACT PERSON:
' YOUR S'I�ATE STATE LiCENSE #
I.ICENSE WiTH qDDRES :
APpLiCA17pN ��
PERM[T TYPE � �GLE FAMILY ❑'1'WO FAMILY
TYPE OF WORK: � O NEW �PUC6M�-niT
DETATLED DESCR,fpTION OF WpRK ( � �
EXP DATE �
��� CTTY
FAX 1t7�_��
O TOWNHpUSE
� ALTERATTONIREMODEL
;1; vl,�,��f' �
�� �T ��SCALC S PEIt MANU� L J 20 p� ppN �k�s` (1NDICAT$'(OTAL
� M/MBER OF EAC�I BELON�
Equipmcrrt Imte!!ed �
M£G: W MODBL: � SIZFJB7U G'J r
MFG: __� MODEL:
SIZFJBI'(7
A/C 525.00 �G' ------+ MODEL: SIZE/BTU
+�: A,.�IRTOqIREXCHANGEp.Rg(g —F�p�CE(GAS)515.00 GASRANQFJOVENSi0.00
L�wILER 535.00 FIREPI�ACE (WOOD) S3S.00 NEW GAS GRtLL S] 0.00
_CHIMNEY LINER El0.00 —��F���S'� GAS UNIT HTR $10.00
DUCT WpRIC alp,pp GAS DRYER T�O.OQ �pppL HEATfiR 535.0p
. _ . 'GAS PIpMf: 4tn rv�
•• . �. wwaw cUvalV.w__A31U,W=�
Number of fiicU�res � g 15,00 _ x S 15.OU = S
Number of fixtures (a� $ZS,Up ! x�ZS.UO m S_
Number of fextures � 535.00 � x 535.00 =$
State Swcharge = s
i
�
INIIKUM FEE 540.06 Totat g S� l%"
� THIS IS AN APpLICATION FOR A PERMtT- T VAL►D UN'C[I, pRp�ESSED
I hereby apply for a buildfng permit aad I acknowled�e that the infortnation above is comptete and accurate; thnt the work wil[ be in
conforrnence with the ordinances and code� of the City� of Fridley arid with the Minnesota Construction Codes; that I understand tl�is i�
not a permit but only an application for- � and Work is aot to start wit}iout a permit; that the work will be in acsord�ce with the
apProved p]aa in the case ofa11 wor ich ires�rgyiew and approval of pl p 4 1
SIdriA7URE OF APPLICANT C � Y �'�� . - _ �i . d ri-1/ /�1 � 1 .4 `��+� i. n : �. �: .
� ' City of Fridley
Building Inspections Department
6431 University Avenae NE, Fridley, MN 55432
763-572-3G04 FAX: 763-502-4977