P - 42224From: 7634283682 Page: 1/1 Date: 6/29/2010 3:45:14 PM
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Building M.�+ C�,ANYCAL `
[nspections R��I��, ���� Ap�►�ICA,TIUN
���3,572-3604 cr�� o►F ��nL�Y
763-502-4977 FA�
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StTE ADD�.F55 �I�a�
Tt115 APPI,ICANT JS:
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rENANT ADDRESS;_„�` CiTY�� �
STATE_., _ZIP
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,'v�� ���' 1�K Cl)MPANY NAMF• �.tFAT{NQ & C �.,.�p -----
SU13M11' A� C'4PY �f' ��N'f'ACT PEIitiC7N• 18550 ��+�"% �'�— '- —' •• ••• •-•
YUUR STAT� Srn7'� �.iCENSe a A��?_���' ���� � -- •••
LICLNSE WITH —i�g�}-e1�$���P OATE _�
APPLICA770N AQDRESS; , �.COrt1 «Ty _ STA7G^, Zlp
PHONE rAX —Y -
PERMI'!' x'YPE ��N4LE FAMILY ❑ TWp R4T�ilLY q TOWt�fHDjISE
TYP� OF WORK; O NEW ��pLACEMG�vr '�I,TER.4troxiREMppE�
UETAII.ED D�SCRJPT(pfV pF WOR1C
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FEES ARF BpSED QN S10.D0 PF,R FIXTLIRE, �XCEPT WHERE fY07ED. FIXT�Iit�:S: INAICATE T¢T NUMBER OF EACH BELpW)
Fquipment lnstsllpxl �qF�; � ,�
M01?EL: i9P SIZFJBTU
MFG� �� MODEL: [��Q3 � SIZ�'J6TU
MFG: -- MODEL: �� Sizfi/BTU
��C T25.00 FIFtEpLACE (GAS) S13.OQ CfAS RANG�/QV�IV SI0,00
AIR T(1 pIR EXCHANCEER�15 FIREp1,pCE (�yQpD) $35.00
__BCyLBR 535.00 �FURNACE S35.UD —N�' GAS GRtLL 510.00
CHlMNF.Y t,�NHR 5io,00 CAS DRYER E 10.00 —�'AS �T � ai D.00
LDUCT WORK Sf0.Q0 GAS PlPING $1�.Oq —��� HEATERS35.00
VEN7ILATQR SI S.OU
Nurn ber of fixtures (a� $ i Q:Op � x$l0.00 =$
Numbee offtxtures (� �1g.00 x $�5.0� _ $ �
Number of fixtures @ $25.48 ! x $25A0 = $ c��� °-'°.
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Number offixtures (a� $35.00 _[` X ��s.00 � ��. °�
s� s��n��e = � so
r�+rtn�[rrM ��E �s.so Toc�r = s �(1✓ �
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TM(5 15 AN APPLICATIpN FOR A P�RNI[7'-NOT VAI,fD UNTIL PROCESSCD
I hereby apply tor a building p���t and 1 aeknowledge that tt�,e j�'a���pq �ove is complelx: and aecur�te; that the w��rk will be in
conformance with the ordinances and cpdes the City of•Fridl�y and with the Minnesota Construction Cpd�s; that I undarstAnd this is
not a permit•but only an sppli t'on f p it and work is not to stsrt without a permit; thst tt�e work rvitl be in accordance with tl7e
approved plan ;n the cas�g p�� � u;r� �,;�,i, �d approval of pt a.
SIGNATURF, OF Ap rCq ptt[NT Nq DATE���
City of Fridley
Buildin� Inspections Department
643I University Avenu� NE, �ridley, MN 55432
763-572-36Q4 �AX: 7b3-502-4977
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