AF - 38753Building �C�IC�, Permit No�f�IQ 3�
Inspections RESIDENTIAL APPLICATION R�"'� By�—
763-s�2-3604 CITY OF FRIDLEY � R�►
763-502-4977 FAX �,.,�2_,�,,
DATE I �L - I 'T - O YOUR �MAIL ADDRESS � � � 'C�[.'�-F' � v� C. CL � � . (�C�
51TE ADDRESS ±� 7i 1'' CL! ��
THIS APPLICANT IS: ❑ OWNER �1C CfOR
PROPERI'Y NpME: � I I e- }' ���� I C?
OWNFR/ ADDRESS:� ZZ CP'��� C� W C� e,t CI1'Y F Y' i c,. ��Lw STATE �'�J 3
�N� PHONE: � l0 3 5 � I �O 1 3 5
CONTRACTOR COMPANY NAME: �l S'� � C�-i'� e. �'N`�c:.ti.-1--; ,r� aL .r }� � C.
SUBMIT A COPY OF CONTACT PERSON: ��—t�
YOUR STATE STATE LICENSE # EXP DATE
r.�covsE wrrx nnnxESS: ! a � 4 a o�1 �l ����+ N vJ crnr � C.�J� G��'o �� sTA�N zd� ��� � �
APPLICATION PHONE � 6� 3 � 3�{ I � r�l c7 FAX �� b�� �{ 3� y'� s�j
PERMIT TYPE � SINGLE FANID,Y � TWO FANID.Y ❑ TOWNHOUSE
TYPE OF WORK: o ivEw �x�rl.nC�' ❑ n[.TEaa'rio�tOn�,
DETAILED DESCRIPTION OF WORK y � Y� S�c�.� ` r✓�CtiC-�-
FEES ARE BASED ON $10.00 PER F'IXTORE, EXCEPf WHERE NOTED. FIX7'URES: (bVDICA7'E TOTAL NUMBER OF EACH BELO�
Equipment Installed MFG: " MODII.: SIZF/BTU
MFG� �'1'�"t-u f�c�JC � f MODII.: SIZFJBTU
MFG: MODII.: SIZFIBTU
A/C $25.00 _FIREPLACE (GAS) $15.00 GAS RANGF/OVF.N $10.�
AIR TO AIIL EXCHANGEER $15 FIRR�I�CE (WOOD) $35.00 NEW GAS GRILd. $10.00
_BOI[,ER $35.00 �FURNACE $35.� GAS iJNIT HTR 510.00
CHIIVINEY LINFdi $10.00 GAS DRYER $10.00 POOL HE�TER $:i5.00
DUCT WORK $10.00 GAS PIPING $10.00 VIIVI7LATOR $15.00
Number of fix4u�es @ $10.00 x $10.� _ $
Number of fixdues @ $15.� x $15.00 = $
Numl�r of fixdues @ $25.00 x $25.� _ $
Number of �r�s @ $35.00 � g $35.IN1= $ 3 5 —
State Surcharge = $ SO
FEE $35.50 Total = $ � J� . S �
THIS IS AN APPLICATIOAI FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclmowledge that the information above is camplete and �e; tl�at the work will be in
conformance witl� ffie ordinances and co�s of the City of Fridley and wit� �e Minn�ota Construction Codes; that I understand this is
not a permit but only an applic�t.ion for a pemoit and work is not to start withaut a permi� ti�at the work will be in accordance with the
approved plan in the case of work 'ch requires ew and approval of plans. /
SIGNATURE OF APPLICANT � PRINT NAME r Zce ��� Ca! v� ��� DATE //� /�
PLEASE NOTE: SEP PERMITS ARE RE TJIRED FOR BUILDING, ELEG°fRICAL AND MECHANICAL WORK
Gity of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977