P - 35828Building MECHANICAI, �
Inspections RESIDENTIAL APPLICATION
�63-��2-3604 CITY OF FRIDLEY �
763-502-4977 F`�x EFPECTIVE2-19-09
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SITC ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
YjOUR E-MAIL ADDRESS � 5�4� ��S
Y o p� e� /�C�,�Q tiJC
❑ OWNER ,'O�ONTRACTOR
ADDRESS:
PHONE:
Pern�it No.:
Received By: ,
Date �� � (� �
e Lx1"l�
CITY STATE ZIP
CONTRACTOR COMPANY NAME TRXOI'11�y S- C-Oc ��Y`�i W n . Iv� a- -
SUI3MIT � COPY Of CON"I'ACl' PERSON -- T,�,.,� J1�,�,�n,Vf ___ _
YOUR STATE STATE LICENSE # �1 A EXP DATE �l,A^
LICENSE WITH ADDRESS: ���� Co. �, r(j � CITY /"`�^ P� G�r�.v�c STATE�ZIPSS"3ba(
AI'PLICATLON PHONE �'(F 3�'Ia" S`�% ��' FAX �Lt
3. `�2 b �1���-
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT �J ALTERATION/REMODEL
I)t:l AILED DESCRIPTION OF WORK � a��a sa�Gk7� .4i
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I� F,ES ARE 13ASED ON $10.00 PI;R FIXTURE, EXC��NOTE�D. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
Lquipmentlns[alled MFG: n Rci[� MODEL: 3SSCl�1I SIZE/BTU� .J
MFG: Rn� /!S) MODEL: �a �a,�✓A S[ZE/BTU ,�U OvU
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MFG: MODEL:
�'.4/C $2?.00 FfREPLACE (GAS) $I5.00
11R TO AIR GXCIiANGGCR $1 i FIREPLACE (WOOD) $35.00
Rc)II.ER'�35 00 �FURNACE $35 00
CIi1MNLY LIN1=R 4�IU (10 GAS DRYER �1000 �
�_DUC"f 41'ORK $IO.U(1 �G,4S P1PWG �10.00
• �
Number of fixtures @$ I 0.00 J x$10.00 =$ �
Number of fixtures @ $15.00 x $i5.Q0 = $ '
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Number of fixtures @ $25.00 ` ; x. $ZS.QO = $ � � � � �.
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� � " � : �,�` F� r�n +2 �.k� �k�,
Number of fixtures @ $35�.00 � � $3'S:OQ = $. c;J �� � " , ��;�� ti� � ��� '�
f1"/ � �'�'� �
State Surcharge ° $��Y� �k+ ri'"
,
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GR[LL $10.00
�GAS UNIT HTR $10.00
POOI_ HEATER $35.00
VENTIL.A�COR $I � 00
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(MIN[MUM FEE $35.50) Tota1= $ ��J
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conf'ormance 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 applicatio permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of at which re uires w and approval of plans.
SIGNATURE OF APPLICANT RINT NAMF LGC/ �j�PN LrnifwTi� DATE � S� lf
PLEASE NOTE:
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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