P - 35404From: Giry of Fridley i o: y51��14�y� Nage: :�b uate: 5r5ituua �:4�:�1 rivi
B�.ilding MECHANI�AL Permit No.._
Inspections RESIDENTIAL APPLICATIUN Received By:
763-s�2-��0� CITY OF FRIDLEY ��1�
763'S�2-4977 FAX �k+N�CT1V�.2-14-09
UATti �• � I . o�CJ �
S1T�, AUUK�SS .��
TH1S APPLICANT 15:
OWNERI
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE W1TH
APPL(CATION
YOUK �,-MAIL AllUk�S5 (��1 ��� �
❑ OWN�R
NAM�: 9-.�Ylrt' ' V--rYKl ( -[�)7
ADllK�:SS: ��Y � 1? � �'�'yiU� S �'�(�E C1TY,
AHON�.: �� � . � �S . `J`- '�7'S�S
A
%IU � �cSY�
COMPANY NAM�,:
CONTAC'f P�RSON: 1408 Northland:Drive Suile 810
STAT�, LIC�NS� 1f (952) 8}EiQ9AT�
AllDR�SS: C1TY STAT� "LIP
PHQME __ _ _ ---- NAX _ _—
PERMIT TYPE �NGL�.I�AMILY ❑ TWO k�AMILY
TYPE OF WORK: � N�W �LEPLAC�M�NT
DBTAILBD DESCRIPTtON OF
❑'fOWNNOUS�
❑ ALT�IiAT10WRkMODEL
FL�LrB AItL BASL�D OV $lU.UO CL�It FiXTURM, SXCL�PT VYHL+RL� VO'L'ED. 1�1X'CURU�S: (IVDICA'PL "C(?'fAL VU:NBL�RON L�ACH BL+LOW)
Equiprrnnt installed M►�G: M011�L: SI'L�/BTU
MN6: M011�L: SI'LElBTU
MNCi: MODtiL: Sl"Ll:/BTU
�AtC $25.00 KIKtiPLAC� (CAS} $ I5.00 CAS 1tANG�V �N $10.00
AIRTQ AlR F:.XCHANG�k $15 NiR�PLAC� (WC�D) $35A0 ^N�W CAS CR1LL $10.00
t1niL�R $35.00 NURNAC� $35.00 ^C1AS UNIT HTR $10.00
_CHIMN�Y L1NtiR$i0.00 _GAS DRYtiRa10.00 POOL H�AT�.R$35.00
UUCT WOItK � 10.00 __ CAS PIPING $]0.00 _V�NT1LATbR $I 5.00
� $� �
THIS 1S AN APPLICA'fION k�RA PtKM1T-NOT VAL1U UNTIL FRAC�,5StiD
[ hcrcby apply for a buildin� permit and I acknowlcd�c that thc information abavc is complcto and accuratc; that thc work will bc in
conformanco with thc ordinancefi and cade� of the City of Fridlcy and with the Minnesota Canctruction Cadc�; that I understand thi.5 i�
nat a perrnit but aniy an application for a permit and work i� not to start without a permit; fiat thc work will bc in accordancc with thc
approved plan in thc casc a woek w' r u rcvicw and approval of plans.
SiGNATUIt� Ol� APPL1CANi�t/"�(/t '�'��-.C.J�-� PR1NT NAM ' � i � �c-- �_UA'f� �� � I . ��� t
City of Fridley t ob�
Building Inspections Dep�rtment �) 33 3� 7�
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977