P - 43887Building
Inspections
763-572-3604
763-502-4977
DATE ` � � < < l l
SITE ADDRESS
TFIIS �PPLIC.aNT IS:
PROPERTY N,.�,¢:
OWNER/ .aDDRE
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTtvE z-t�-o9
Y E-MAII,
�- t�
❑ O\1NER CONTR_aCTOR
�� 1SQ „—
/w � �.L/� �+ �
COnIP.�NY N.-1I�LE. wa� wa� aa � �..�..� �...7 .,. . ... ................ ..
CONTACT PERSON: m0
STATE LICENSE #� R 17 R2d_7� DATE
ADDRESS:
PHONE
F�IIL1' ❑ "fu'O F,��IILl'
0 NE�l' �EPLACEr•tENT
DETAILED DESCRIPTION OF WURK
FAX
❑ TOWNHOUSE
❑ ALTER.a1'ION�'REr4UDEL
�
Pennit No.:(�(� ; � ���'
R - i�-ed � �- �
Da e �e�c'�
ST,�TE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBII2 OF EACH BELOVI�
Equipment Installed MFG: MODEL: SI7.EIBN
MFG. MODEL: �` O SIZFIB �� V
MFG: MODEL: SIZFJBTU
_A/C 525.00 FIREPLACE (GAS) S 15.00 GAS RANGE/OVEN 510.00
_AIIZ TO AIIZ EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOII.ER 535.00 �F[JRNACE $35.00 GAS UN1T Fi'TIt 510.00
CFI�INEY LINER 510.00 _GAS DRYER $10.00 POOL HEATER 535.00
DUCT WORK 510.00 _GAS PIPING 510.00 VENTII.ATOR 515.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN'i1L PROCESSED
I hereb_y apply for a building pemiit and I ackno�.uledge that the information above is complete and accurate; that the t�-ork ��•ili be in
conformance �cith the ordinances and code t e ity of Fridley and �a ilh the Minnesota Construction Codes; that I understand this is
not a ernlit but onl � an a ca or a m work is not to start �vith t a perniit; that the wo t;-il1 be in acco ance �vith the
approved plan in the c of all w yel�i h r quires eview and approval of p a�s. _ ,� � � ,
SIGN.4TURE OF
N_�IviE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
/