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Inspections RESIDENTIAL APPLICATION Received By:� �
763-Si2-3604 CITY OF FRIDLEY D�� ��� ���
763�5�2-49%% FriX EFFECTIVE 1-1-2011
DATE�(0'' J�Ti YOUR E-MAIL ADDRESS �'+��'LQQ/{P��,�Iq�N lA'O� � C.O►�
SITE ADDRESS j IO (.C�Aj� �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
NAME:
apD�ss:
PHONE:
COMPANY NAME
CONTACT PERSO]
STATE LICENSE #
ADDRESS:
PxorrE Co/ 2 - 3
3 —2t 7
PERMIT TYPE �INGLE FAMILY ❑ TWO FAMII,Y
TYPE OF WORK: ❑ �w ❑ xErr.ac�rrr
DET,�ILE]�J DESCRIPTION OF WORK q,d2 :
�
STATE__ZIP
Lic. 6C0512060
�rDa� 2700 FAIRVIEW AVENUE
cITY ROSEVILL , ,��
FAX
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
G�/(.[1lly �7'��/"u +fSf�Ni L ��'��C.i ./�n
ZIP
FEES ARE BASED ON $10.00 PER FIXTiIRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�
PROVIDE HEAT LOSS CALC'S PER MAIVUAL J 20116 ASHRAE HANDBOOK
Equipment Installed MFG: _ MODEL: SIZFIBTU
MFG:
MODEL:
�C*� MODEL:
A/C $25.00 �IREpLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 FURNACE $35.00
CHIMNEY LINER $10.00 AS DRYER $10.00
_DUCT WORK $10.00 �GAS PIPING $10.00
SIZEBTU
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UIVIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS�AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby app for uilding pernut and I acknowledge that the infonnation above is complete and accurate; that the work wili be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit an work is not to start without a permit that the work will be in accordance with the
approved plan in the case of all work whic equu review and approval of plans.
SIGNATURE OF APPLICANT v � PRINT NAME �LL LC � �a' � .S �t`I �1�ATF. <</ �!� � �
APPROVAL
City of Fridley
�uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977