P - 42225From:
Building
Inspections
763-572-3604
763-502-4977 FAX
UA7'ti�Lf
S1Tt AllUR�S5
TH1S APPLICANT 1S
PROPERTY
OWNER/
TENANT
CONTRACTOR
SU BMlT A COPY OF
YOURSTATE
LICENSE W1TH
APPLICATION
PERMIT TYPE
TYPE O�' WORK:
of Fndley lo: y�`Lttti144a1 Nage: y5 uate: 5�5t1uua �:4�:�t rn�i
MECHANICAL Permit rto.�°. ; �
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RESIDENTIAL APPLICATIfJN ReceivedrBy:
CITY OF FRIDLEY nate��'�: `
YOUR �-MA1L AllUR�,SS
� OWN�R
NAM �:
AUllR�,SS: CITY STAT� 'L1P
PHQN�:
COMPANY NAMB:_
K�NTAC'f P�RSON:
STAT� LICHNSH fl
PHON�,
❑ S1NGL� NAMII.Y ❑ TWO KAMILY
❑ N�W ❑ RtiPLACtiM�NT
DETAIGED DESCR[PT[ON OF WO�RK
O 'fQ WNHOUSt
C] ALT�KA7IQN/RtiMQll�L
-r
STATti 'LlP
FEL+B AI�L BASL�D O� 510.00 PLR F1X7'UltE, �LCL�P7' WHL�RL� VOTL�D. FIX'1'UItL��: (1!1111CA'1'L'C07"AL 11UWBElt OF L�ACH BBLOW)
Bquinmerrt lrastnlled MNG: MOU�L: ('� y� L�. ��/Ss'C -11 O Sl'LF/B7'U O o c�
Mrr,: Mout�: �IA� 13 Lo3Co sur�dru 3
�A/C �25.00
AIIiTQ Allt �?CCHANG�R $IS
�13QILtiit $33.OQ
CHiMN�Y LIN�)t$10.00
'llUC'f WQRK S IO.QO
M}T(i: MnD�L:
NiK�PLAC� (GAS} $ I5.00
�FIRBPLAC� {WC1C?D) $35.00
NURNACE $35.(�
�C,AS DRY �R $10.00
SI'L1i/13TU
GAS ItANt;�/OV�N $10.00
N�W CAS CR1LL $ IQ.00
GAS UN1T HTIt $I0.00
POQL H�AT�R �35.00
V�N'CILATOR �15.00
THIS 15 AN APPLiCAT1QN N!nR A P�KMIT-NOT VALIll UNT1L AROC�SS�ll
I hcxcby apply for a buiiding permit and I acknowlc�lgr. thgt thc information abavc ig complctc and accuratc; that thc wark witl bc in
conformancc wifh thc ordinanccs and codc±.q of thc City of Fridlcy and with thc Minncsota Construction Codac; that [ undcrstand this i�
not a permit but only an application far a permit and work is not to start without a permit; that thc wotk will bc in accordancc ith thc
approved plan in thc casc wot hich � uires revicw and approval of plra�ns,._ �
SIC,NATUR� OF APPLICANT PR1NT NAME � � UAT� v_ � v
City af Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
7d3-572-3604 FAX: 753-502-4977
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