P - 84355From: 7637551'554 Page: 2/2 Date: 10/23/2012 9:51:45 AM
BU11t11I]g ��i ��,E�.�'��,E��. Permit No.:C-UI � U I ill.�'
�nspect�o�s RESIDENTIAL APPI.,I�.A.�'�+��T �e�e�"Ed a�Y.,
� G,.... _
763-572-3604 �ITY OF FRIDL�Y �'�R��.� � � ��
7�i3-502•4977 FA� ,,.,�,_, .,,.,, . . ��,�
un�re-.-1�=.4
'�ITF F1t)1)RFS5
Tti15 APP�1C'AN1' IS:
OWPIEW
T�NANT
SL1BII�IT A C'�PY (3F
YOUR STATE
LICENSG W!'I'H
,4,PPI�1('ATIpN
PERM�'�' TXP�
i'YP� OF WORK:
YQUR E-MAlL ADDRF5S
O UW�ER
A�)fIR'F.SS; '
PHUNF: �
CUMPAtiY NnME?: ����
E'UNl'AC'i I'FRSUN: _��k��� .,
�'rAT� U(:EHSE a �
('ITY S'fAl'L 'Llt'
� ��C •
L)A 1'L y!� `�t �-�
G CITX � ' G' _,___.S'1'A'I'F3lVlllf"L1P�r
PHUNE—lf�� ~��_ FAX �__��L_r [,F�l��f
�$IN(iLf: FAMIi.Y O TWO FAMILY ❑'TOWNIiUU5F
�NFW ❑R$I'LA(`EMESN7• OAI:1'fs1iA'I'IUN/RFM(?UHI.
[3ETAIL�D DESCR1PT10N O� WO[tK
r
FF.F.S ARt! �ASiD Ol� Sf0•0� P$R FtXTU1i$, �XCEPT WiIERE N07'�;D. FIXTl;RES� (INU[(;ATE �'07A4 NUMBF,R OF EAL'H SEtUW)
PRqVIp� HE,4T 1,pSy {;At,�'S Pk;R 11�IANUAL J 2006 ASIIRAE HANABOOIC.
F:yui{�mc�t lnata��ed M'��C;: _,_,_ MUllLL� SIGFJBrI1 �,,,�_
MI�f: ......_�_ h4{?llL'L: S(GFJaTU
M'FG: MUDHI,: � 51't,F:lH'i'lJ �.._._. _.._
A!(' �25.00 . FiiiFF`I.A('� (t:�AS) S 14.0U � �.^.�-- CiAS RAN(iFJt)VF.N Slfl,Up ���
~A11i 1'0 AIR h',XC:MANG��RSIS F[Et�l'I.AC'G (WUUU) 335.110 NEW (i.4ti GILI1.l. S1U.UU
�8<71LER S33.if� '1't�Khinc:L•'szs.�u .,• GAS linii�l' E�I'i'K xlo.ou
. (;HIMNEY [,tNElt SIU.W �C;AS DRYER $IU,UU _ I'(.)Ul. I•lL.41'l:R �35.UU
__��U(•°C WV�K 5T0-W �4AS PtPING SIO.M� ��VIiN'fll.Al'UIt 3t5.qV
Number of fixmres Q$10A0 _ x$10.00 =$
Nurtlber of �xtu�res (�i $15.d0 _ x $15.UU = $
Numbor pf fixCUres (a� $25•00 _ x $25.00 = $
Numbcr of fixtures Q$35.00 � x�35.00 ¢$
State Surcharge =
(MINIMUM FEE S35 qkus suXChsxge) Xocal =$�A���
'f'! ItS 15 �1N APP�ICA'l'ION FQR A P�KMI'I'-NC)'I' vAi,]ll UN'IYI: PROC'EtiSL'U
1 hereby appty for a building permit and [ acknowted�e the iMformarion above is cnmplctc and accurate; that the wark wiil be in
confo►m&nce with the ocdinance� end eodc • of the Ci qf Fei Itiy and with thc Minnesota Construc;tivn Godcb; that I und�rstand this is
not a permit but only an a{�plication far a pe it an work i• not to start without a permit; that the work wilt bc in aceotdanca witl� the
appmved plan in the case of k i rcqu view nd approval of pt�ns,
SI(iNA'I'lIItC• OF APVLIf'AN'f �_ PRINT NAML ��,��^?� ,y,�I)A��''Z � �~,.._..,
6431
�EQLIlkED FOR �U1�DING, ELECTRZC
`�City o� �ridley
� Inspections Department
izy Avenue N�, Fridiey, N1N 55432
3604 FAX: 7fi3-502-4977