AF - 43185�� I�
City of Fridley, 1Vlirm..
B�TILDING PERIVIIT
�Date: ... ----'-:..�. ___.'- _ ...._ .—..._—.___---...____..._.
Owner: ..--•-- - ---�--------._.%_..._.�.�.�....� _....._. .------- - ---- Builder
Address -----_..--------.......__..�........._._.._...._...—.._..�.. _.___ Addres.s
1�T° 4436
� LOCATIONi OF BUILDING "
No. ...r.......��.._.... S,�t ......... .. . ._.._._ .... ...._ ....._.....�i�_.�1._.._...._.... p of �t .__.._........__........... .._............ �...._...._..._._...._
Lot .......... °..�.. ...........-....... Block -------...i.....- �- ..... - .. ddition or Sub-Division . _ .. ... .. . ... .-�- --..... _........_....... .--- .... ... ..��/
'�J �
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Corner Lot ................... �............ Inside Lot ....._.. ��......_.... Setback .�...s�...---.........---�--.. Sideyard ...._........�.�..._......................._
B� --.._......._.
Sewer IIevation .--�--...--�....�...�...---------�-�------�--�--�----..._ .............---•�---- Foundation IIevation .........-�� -�--�~��d---�•--��.--------..._..._.._...._..
DESCRIPTIOIV OF �UILDING
To Used : i' �
.•
/- - � f -�
... ... ----- ............._.._. -- -
.... Froat - _.. Depth ...�_;�.--- Height ...�..�.... Sq. F`t. .. .. ...
.. .
6r��=°�"--- --- �-..g.......... Front �e ..:.......... Depth ...r�c... � . Height ._/ �.... Sq. F� ��... .
1j�pe Construction _---1..�. . ....... .. ._ . . ..... Est Cost �. `��. .. f-.�� ��. �^To be Completed ...
In consideration of the issuance to me of a permit to cons e building described
the proposed work in accordance with the description above � forth and jn comp�anc�
ordinances of ttie city of Fridley. f/ �/
In considera.tion of the paymettt of a fee of �.. �.., �mit is hereby granted
Cu. F� ���
Cu.Ft. • .......................
e, I agree to do
all provisions of
..___.._._.__._..._____._.._._...___....... to construct the building or addition as described above. This peimit is granted upon
the express condition that the person to whom it is granted and his agents, employees aad workmen, in all work
done in, around and upon said building, or any gart thereof, shall conform in a]1 respects to the ordinances of
Fridley, Minnesota regarding location, construction, alieration, maintenance, repair and moving of buildings
within the city limits and this permit may be revoked at any time upon viola ' of any of the provisions of said
ordinanc�s. ��a�� % � � �
Inspector
NOTICE:
This permR does not eover the aonstructfon, installafion for wfring, plumbing, gas heafing, sewer or wafer. Be sure to see
the Building Inspeeior for separate permifs for these items.
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HfAT LOSS CALCU[ATIONS �;,�` � °� � �DEPARTMENT OF BUILDINC�S _ � �•
Weatherstrips A.S.H.V.E. Construction No. Insulation
Guide
Windows I Doors Reference Out. Wall Int. Wall C,eiling Roo$ F7oor Kind How Applied
Yes—No Yes—No 19—
� Fl.� ��:,�? Room � Length �� Width .� Height �' P FI.� ` Room Lengtlt Width Height
Windows and Doors—Crackage and Area Windows and Doors—Crackage and Area
�Vidth HelBht No. ot Llneal tt. Area Wldth Height No. o[ Lfaeal tL Area
No. o[ pane ot pane lighta ot crack ep. ft. No. ot Dane o[ pane IfBbte ot crack eQ. it.
� !� .'� ��''� iP G? !�. , � ��.1. . � .� r`� _ � * r
Infiltration '�' '� ���
Glasa � �"'
Exp. wall "�,� °
Net exp. wall �' � �' {� "� h �'s
Int. wall
Ceiling
Floor � �
`I'otal Btu. " �
Required sq. ft. E.D.R. or aq. ina. W.A. Leader area
Ft.� ;�''. .�'� Room � Length �' Width Height
Windows and Doora—Crackage and Area
Wldth Helsdt No. ot Llaeal tt. Ares
Na. ot Dane ot pene lighte ot crack ep. it.
� �� � , �
Coef. Btu
In6ltration �,�
Glaaa `
Esp. wall � °'
Net exp. wall `
Int. wall
Ceiling
Floor '
1'otal Btu.
Required sq. ft. E.D.R. or sq. ins. W.A. Leader area
� Fi. '� Room � Length -';� � Width
Windows and Doora--Crackage and Area
Width Helght No. ot L1nea1 tL. Area
No. at yane ot Dane 116bts o[ crack sp. tt.
Btu
lnfiltration I �° °"
Glaaa a�' � �
�p. wau
Net eap. wall ° �
Int. wall �
Ceiling �.'�
Floor � �
Tbtal Btu.
Required aq. ft. E.D.R. or sq. ina. Q(.A. L.eader atea
Bhl �
Infiltratioa
Calass
�. Wau
Net eap. wall
Int. wall
Ceiling
Floor
Total Btu.
ft. E.D.R. or aq. ins. WA. I.eader arxa
Windows and� Doora--Crackage ana Area
Wldth BelBht No. of Llneal tt. Area
No. of yane of pane llghts of crack eQ. [t.
� '� N"§ �"
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Infiltration �
Glass
�p.,�►au
Net ezp. wall
Int. wall I
Ceiling � a
Floor � � . `�
Total Btu. ' � � I
Required sq. it. E.D.R. or sq. ins. W.A. l.eader area
I �.� ��_ �m � ��, Widch Hei�ht
Windowa and Doors—Crackage and Area
Wfdth Height No. of Lineal it. Ares
No. o! pane of pane IIBb� ot crack sa. t4
� �
Coef. Btu
In6ltration =� �
Glaas
E�. wall �
Nec exp. wall
Int. wall
Ceiling
Floor
'fotal Btu.
ll Required aq. k. E.D.R. or sq. u►s. WA. L.eader area
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n.� �,.� - -
HEAT LOSS CALCULATIONS DEPARTMENT
Weatherstrips A.S.H.V.E, Construction I�
Guide
Windows I Doors Reference Out. Wall Int. Wall C,eiling
Yes—No Yes—No 19—
Fl.�,�.��; E Room � Length d�� �Width f� Height
Windows and Doors—Crackage and Area
tVidth Helght No. o[ Llneal L. Area
No. ot Dane ot Dane. lighte of crack eq. ft.
� � � � P '� �'�•
Coef. Btu
Inhltration �. � �° ° ,�"�
Glaaa %' � � ? � o�
Eap. wall "? �' °�,�
Net exp. wall ;s �` r,L� � � � /'�' ' �:
Int. wall
Ceiling � ca � . � �,,
Floor / °�'4L.�,' ° a' �+ ,�� � .�
7'otal Btu. � � �',�;
Required sq. ft. E.D.R. or aq. ina. W.A. l.eader area
Fl.� -.�� . Room � Length � Width �
Windows aad Doora—Crackage and Area
Width Hefght No. o[ Llneal tt. Area
No. of yane ot pane iisncs ot crack ra. ft �
�
In6ltration
Glasa
F�cp, wa�
Nee ezp. wall
Iat. wall
Ceiling
Floor
Tocal Btu.
Height
Coef. � Btu
Required sq. ft. E.D.IZ. or aq. ina. W.A. l.eader area
Fl. Room � Length Width
Windows and Doors—Crackage and Area
Wldth Height No. oL Llaeal tt. Area
No. ot Dane ot paae Ilghta ot crack eq. it.
�
Infiltration
Glasa
�p. Wau
Net e:p. wall
Int. wall
Ceiling
N loor
Tbtai Btu.
Required sq. ft. E.D.R. or sq. iaa. W.A. Leader area
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sue�etT PERMI
City of Fridley 2 919
AT TME TOP OF TME TWINS g � I L D I N� P E R M I T
r
; � RECEIPT NO.
� ; v ����_ COMMUNITY DEVEIOPMENT DIV. ���
r � � PROTEC7IVE INSPECTION SEC.
� . ,
� j �'�'1 � CITY HALL FRIOLEr 33��2 NUTABEP NEV D�T6 PAGE Oi APOqOVED 8Y
�'""'�" �'' 612-571-3460 910-Ft5 4/13/99 / /
10B ADDRESS 140 Craig Way NE
t LEGAL �07 NO. BLOCK TRACT Oii AODITION SEE ATTACHED
oesca. 3 1 Pearson's Craigwa Estates SHEET
2 PfiOPERTYOWNER MAILADDR�S$ ZIP PMONE
Neal & Lori Robinson 140 Crai Wa NE 571-7716
3 CONTRACTOF MAIL ADDRESS ZIP PMONE LICENSE NO
Same
a ApCNITECT OR DESIGNER MA1 ADDRESS ZIP PMONE UCENSE NO.
5 ENGINEER MAIL ADDRESS 21P PHONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW Q ADDITION ❑ ALTERATIpN � REPAIR O MOVE O REMOVE
8 DESCRIBE WOfiK
Reroof House & Garage (28 Sq) Tear—off
9 CHAN(3E OF USE FROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
CONSTRUCTION WORR HOURS: 7:00 am to 9:00 pm, Monday thru Friday; 9:00 am to
9:00 pm on Saturday; No work on Sunday.
SEPARATE PERMITS ARE REOUIRED FOF ELECTRICAL, PLUMBING. MEATINp, TYP� OF CONST. OCCUPANCY GROUP OCCUPANCV LOAO
VENTILATING OR AIF CONDITIONING
THIS PEiiM1T BECOMES NULL AND VOID IF WORK OR CONSTRUCTION 20NING SQ. FT CU FT.
AUTMORIZED IS NOT COMMENCED VyITHIN 80 DAYS. OR IF CONSTRUCTION
OR WORK IS SUSPENDEO OR ABANOONEO fOR A PER100 OF 1�0 DAYS AJ
ANY TIME AfTER WORK IS COMMENCEO. NO DWLG. UNITS OFFSTFEET PAFKING
I HEREBY CEHTIFV 7HAT I MAVE READ AND EXAMIN�O THIS APPLICA71pN 1 STALLS GARAGES
AND KNOW TME SAME TO BE TRUE AND CORRECT. ALl PROVISIONS OF LAW$ yp�UATION SUFTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL QE GOMPUED
WITH WMETHER SPECIFIED HEREIN OR NOT. TNE GRANTING OF A PERMIT �2�399 $1.ZO
OOES NOT PRESUME GIVE AUTHORITV TO VIOLATE OR CANCEL TME pEqM17 FEE SAC CMARGE
PROVISIONS OF AN T STATE AL LAW REGULA7 NG CON-
STRUCTI OR T E RMANC ONSTRUCT�ON �74.7.5 Fire S�'i �2.40
�" PLAN CHECK fEE TOTA� FEE
� . % $78.35
S�GNSt A CON'AA OA uiHOA�ZEDSGENi �0 E WMEN PROPE VALIOATED 7HIS IS YOUR PERMIT
c /�
S�G A1UAE O� OWNEA ��F OWNEA BWLDEA� �O�TE� � BlD ��a5o � qciE
s s '
NEW [ ]
ADDN [ ]
�-� I l
ConstructionAddress :
Legal Description:
Owner Name & Address:
CITY OF FRIDLEY
SINGLE FAMII.Y AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION
f
%
0
�
Effective 1 / 1 /99
��X ���
�
Tel. �/ �r,%��' ,
Contractor: /� �; MN LICENSE #,
,
Address:
LIVING AREA:
GARAGE AREA:
DECK AREA:
OTI�R:
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IlVIPROVEMENT
Length Width Height
Length Width Height
Length Width Hgt/Ground
Tel. #
Sq. Ft.
Sq. Ft.
Sq. Ft.
o�$ � r�d�'e5
Construction T e: ''� ''�e—��� Estimated Cost: $ � 3��
yp ��
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft =/, ..Ft x� _ _$
DATE: APPLICANT:
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
CITY USE ONLY
do
�
Tel. ra, Jp'I�� �%%
r
$ ��/ � s Fee Schedule on Reverse Side
$ �. �-1 0 .001 of Pernut Valuation (1/lOth%)
$ / . 2 0 $.50/$1,000 Valuation
$ $1050 per SAC Unit
$ $5.00 (State Licensed Residential Contractors)
$ Alt. "A" or Alt. "B" Above
$ $450.00 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement Necessary [ ] Not Necessary [ ]
� `�.35�
BUII.DING PERMIT FEE SCHEDULE
The Chief Building Official shall, before issuing pernuts for the erection of any building or structure, or for
any addition to any existing building or structure, or for any alteration or repair to any existing building or
structure, upon application therefore, require the payment by the applicant for such permit of fees to the amount
herein below set forth and in the manner herein provided to-wit:
TOTAL VALUE
$1 to $500
$501 to $2,000
$2,001 to $25,000
$25,001 to $50,000
$50,001 to $100,000
$100,001 to $500,000
$500,001 to $1,000,000
$1,000,001 and up
FEES
$21 (Minimum Fee is $21 plus surcharge}
$21 for first $500 plus $2.75 for each additional $100 or
fraction thereof, to and including $2,000
$62.25 for first $2,000 plus $12.50 for each additional $1,000
or fraction thereoi, to and including $25,000
$349.75 for first $25,000 plus $9.00 for each additional $1,000
or fraction thereof, to and including $50,000
$574.75 for first $50,000 plus $6.25 for each additional
$1,000 or fraction thereof, to and including $100,000
$887.25 for first $100,000 plus $5.00 for each additional
$1,000 or fraction thereof, to and including $500,000
$2887.25 for the first $500,000 plus $4.25 for each additional
$1,000 or fraction thereof, to and including $1,000,000
$5012.25 for the first $1,000,000 plus $2.75 for each additional
$1,000 or fraction thereof
DRIVEWAY DEPRESSION ESCROW
(Concrete Curb 5treets Only)
Alternate "A": Removal and replacement of curb and gutter only - Driveway width plus 6 feet times $15.50.
Alternate "B°: Removal and replacement of curb and gutter and install a 3 foot wide
approach with 6 inch depth - Driveway width plus 6 feet times $23.25.
VERIFICATION OF FOUNDATION
Permits for construction will be issued a minimum of 24 hours from the time of application to allow for proper
review of the proposed structure and of the construction site.
A Certificate of Survey of the lot, showing the location of the foundation once it has it has been constructed
will be required before proceeding with the framing.
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ADDRESS/ �O _%
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HEAT LOSS DATE HTG. INST. R'—G� °OZ
SOLD BY 1 A. C�
Elecvical Work By -P
TYPE OF HEAT GA FA HW S AM SPACE HTR.
MAKE t�a�i f Q 1� GAS DESIGN
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APT. FLOOR CRY''�� SUBURB
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INSTALLED BY `�l C.� �6 �'C'i
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KIND OF LINE �.1 � SIZE NONE
E3f8ff IiOQd 'E' --- --Re9 er
Filters Size �� �7 t�( Number �
Chimney Location Inside Outside
Chimney Construction K r-t
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Door Pressure Lightlng Inst. ��
Date Tested � � ° �Z
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Name of Tester
Pressure Percent CO2
Input CFH Percent Oz
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- �- - «o
Building �Cj�G� ermit No.•
Inspections �S��i �j'I�, AppLICATIOl�T R�ived $y:
763-572-3604 CI� �� �.���: . . � , � Date Rec'd: —�� -��
DATE — ` YOUR E MAII. ADDRES'S �
s1�,�D�ss I Pa,� �,► P � .
THIS APPLICANT IS: O OWNE+R
PROPERTY Nq�: ��'
OWNER/ nDDRESS:�
TENANT
CONTRACTOR coMpqx�N,�: Sharp Heating & A.C.
SUBMIT A COPY OF CONTACT PERSON: FlOyd JOSW3,Ck �
YOUR STATE STATE LICENSE # E}� DATE
LICENSE WTI'H ,�D�s: 7221 IIniversity Ave�. N. E. � Fridiey sTAr� 1MIl�T�, 55432
A.PPLICATION pHONE_763-572-045 FAX • • . '
PERNIIT TYPE
TYPE OF WORK:
�SINGLE FANIILY ❑ TWO FAMILY
� NEW �REPLACE1vIENT
DETAILED DESCRIPTION OF WORK
❑ TOWNfiOUSE
❑ ALTER�TION/REMODEL.
PER MS 16B.665 the permit fee is a minimum of 515.00 or 5% of t6e total �cost up �o $50O:n0; whichever is .greater, for.the
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should refleCt only the cost of labor )
Labor cost under $300 =$15.00. Labor cost between $300 to $500 = cost of labor x.OS = �
FOR PROJECTS Wf�RE LqgQR EXCEEDS $500, FEES ARE BASED ON $10.00 PER FIXf1JRE� g}(CEPT WI3�RE.NOTED.
NUMBER OF EACH BELOW) �, . FIXTURES: (WDICAT$ TOTAL
Equipment Installed ' MFC'i: MODEL: ' SIZFJB•fU •
MFG: MODEL: SIZFJBTU
�`'��� MODEL: SIZE7BI.0
A/C 525.00 _FIREpLACE (GASj $15.00 _GAS ReWGFJOVEN $10.00
_,AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00
_BOILER $35.00 _FURTIACE $35.00 �W Q!°`S ��L $10.00
_CHIMNEY LTNER $]0.00 _GAS DRYER $10.00 —C'� �T �$10.00
_DUCT WORK S10.00 GAS PIPINCi $10.Q0 . PQOL HEATER 535.00
. -- VEI�TTII.ATOR $15.00
Permit Fee $ ' Number of fixtures �$tp,pp x$10.00 =$
Surcharge $ .50 Number�offixtur.es
TOTAL DUE $ Ca: $15.00 x $15.00 = $
. Number of fixtures @ $25.00 � X $25.00 = $
Number of fixtures @ $3S:OU x $35.00 = $
State Surcharge = $ 50
Total = $ .,�, p
THIS IS AN APPLICATION FOR A PERNIIT NOT VALID UNTII, pRpCESSm '
I hereby apply for a building permit and I acknowledge that the information above. is com lete :and acc
conformance with the ordinances and �odes of the City of Fridley and with the Minnesota•CoiLstruction � d�es�; that�understandlth s s
not a permit but only an ap ication for a permit and work is not to start without a pertnit; tha t t he wor k wi l l be in accordance w�th tMe
approve d p lan in the case of work w i r es review and approval of plans.
SIGNATUREOFAPPLICANf . PRIN1'NAME__ V��Illfj �.�����p,� .,,,,,, ��,L�_/�Q
City of Fridley
Suilding Inspectians Department
6431 University Avenue NE, Fridley, MN 55432
� 763-572 3604
FAX: 763-502-4977
Building BUILDING Permit No.: `�CaZ�� !I �I?��
Inspections RESIDENTIAL APPLICATION ived B:�' C� � a
763—s�2-3604 CITY OF FRIDLEY ������ � 010
763-502-4977 FAX �FE�.r�v�,_,_�olo
DATE � °' S �!' ._ �-� s � YOUR &MAIL ADDRESS
STfEADDRFSS � y(i �1(/�I4:� 4�4�°� j�l (:- F,n.�o] ,�='�/ G1i1,fJ
THIS APPLICANf IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NnME: I�l �t'�(r } I...of!'-� �o �'�.trl �c�
TENANT nnn�ss: R�f c� C►�-v9.+ �, u�c�-i IU t crrY 1�'--aC�L.t� STATE WW Z[P h a�"`-�� Z
rxor�: %!�3 -- $`7 I — ?7 ) (c
CONTRACTOR NAME: v1 S GFd N.�.� � � "ez+•! �, �,t GT.+��3
SUBMIT A COPY OF STATE LICENSE # iVl�'�)
YOUR STATE LICENSE �`�Z `� EXP DATE � 3 i ?�- il
ANDCERTIFICATEOF ADDRESS: �►ii�F't�V`�� �Ei0L�5 �.�i? (a��.e�l��/` IW��Y 1� STATE�ZIP ��O`�'3
Il�TSURANCE PHONE ' 7�JG' - I'Z7�3 , FAX ,�SI�— 4� L=-- �7l0`�
PROPERTY TYPE �SINGLE FAMII,Y/NEW CONSTRUCPION SIZE
❑ TWO FAMII.Y/AiEW CONSTRUCTION STORIES
PERNIIT TYPE � �DI1'ION ❑ G�,itnGFSSxEn �wIlVnowS
❑ BASII�IIIVT FINISH �ROOF O DRAIN TII,E
� DECK d�'SIDING {i�OTHIIt j�N5G1Y+� SC�se-If1T6 %�iiC�c�ta=�� Da(��,''tj
❑ SWA�IIvIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCI'ION ❑ ADDITION
�MAIl�TENANCF/REPAIR O ODII.ING
DFSCRIBE WORK BIING DONE: IUG�" ��'� ��� Q�`'�`�i ��-c Y N� 5,.� �-��l � w� ��r-nw t� v.�; �
SIZE OF IMPROVEII�IIIVT LINGTH �VVIDTH HIIGHT SQ FI'
RQOFING f C ❑ HOUSE ONLY
�- BASII�NT REMODII.ING SUBMIT:
NUMBER OF SQUARES �� '�HOUSE 6c GARAGE
1. Existin� Floor Plan
GARAGES � ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSID SIZE: ❑ DETACHID GARAGE 3. List of structu�al members to be used
PROPOSID HIIGHT:
SIDING FOR NEW CONSTRUCI'ION INCLUDING DECKS,
O Vuryl ��grt ADDITiONS_ & PO�tCHES SUBMIT:
❑ Aluminum � Trim 1. Site Plan/Survey showing the existing struetures
l� pther� � g� and ProP�sed Pro,j�t-
2. Two sets of construction plans
wnvnows 3. Energy Calculationg
IN EXIS1'ING OPININGS �3'es ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR N�'W OPININGS-DESCRIBE SIZE OF MANUFACfURE STICKER ON WIIVDOW.
OPENING CHANGES & Ll`I^a �1w.��t ✓� i�it i r'( 5
TYPE OF WINDOW TO BE INSTALLID ✓ic�.'v' v� N�IMBER oF WINDOWS ��'
ALL NL�'L�'S AKL BASI�'.11 UN VALUA'1'IUN, llV(:LUll1NG THE COST OF LABOR AND MATERIALS:
�IJSIW . 77;� � nn� iT u n t�EE SCHEDULE)
JOB VALUATION $ Q,�� n(�li <�.r� �� �� " OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Ctit Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tofal Dae
$
$
$
$
S� Back Page for Fee Schedule
65% of Building Permit Fee
.(}O1 times the total job valuation
.ODOS x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractots)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Ag�ment necessary ( ) Non Necessary ( )
Muke ch�ks pavable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PIItMIT-NOT VALID UNTIL PROCESSID
I hereby apply for a building pernut and I aclmowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinan and c�es o City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
pemut but only an applir,�ti ork is not to start without a permit on site; that the work will be in accordance with the
approv� plan in tlie case of 1 w" review and approval of L��
SIGNATURE OF APPLICANI' PRIIVT NAME�, °/`�"��C,�J � DATE ���v 7-� I�
APPR(1VAi.1NCPFl`T(1R CT(.NATfiRF
FOR PLUMBING. ELECTRICAL AND MECHANICAL WORK