P - 84270t�uilcting
Inspections
763-572-3604
763-502-4977 F
DATE�
S[T'E �DRESS _
TFIIS ?.PPLICANT IS:
PROPERTY
OWNER/
TENANT
1V1�C:HAN1(;AL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 2-19-09
C
N.�: `
:aDDRESS:
PHONE:
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E-MAIL
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Recei�-ed B��: I ' ►°Q'
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COIVTRACTOR COAIP.aNY N.�4E. 5iaf1d8fC1 t'1e2iif19 6� HIt �.v��uiuv�n�i�
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SUBMIT A COPY OF �ONTACT PERSON: _���a��s�r�����4a�
YOUR STATE STATE LICENSE # F 17_R7d_7E� DATE
LICENSE V✓ITH �DRESS: CITl' STATE ZIP
APPLICATION
PHONE FAX
PERMIT TYPE I�S�GLE F,�.I�IILl' ❑ TWO F.Mffi,1' ❑ TOR•NHOUSE
TYPE OF WORK: I ° ��i� �PL.4cEr-�Nr
DETAILED DESCRIPTION OF WORK
❑ u.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED_ FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi�
Fquipment Installed MFG: MODEL: SIZF/BN
MFG:�- MODEL:3 � z� SIZE/B ��
MFG: MODGL: SIZFJBTU
A/C S25_00 FIREPLACE (GAS) $15_00 GAS RANGE/OVEN 510.00
_AIIt TO AIIt EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRII.L 510.00
BOILER 535.00 �FURNACE $35.00 GAS IJNIT HTR $10.00
CHII�IIQEY LINER $10.00 GAS DRYER $10.00 POOL HEATER 535.00
DUCT WORK $10:00 GAS PIPING $10.00 VENTII.ATOR $15.00
THIS IS A.i��83'd FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building perniit and I acicnow�ledge that the infonnation abo�e is complete and accurate; that the u�ork will be in
conformance �uith the s and c Cih� of Fridley and �a-ith the Minnesota Construction Codes: that I undetstand this is
not a e ut but o� a a n or a miit nd work is not to start ti�•ith t a ernlit; that the wo t3ril1 be in acco ance tvith the
approved� m th case of v�rk requ` es review and approval of p a�is. P, , � � � �
SIGNA'
N_�hfE
City of Fridley
Building Inspectioas Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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