P - 35507Building
Inspections
763-572-3604
763-502-4977 F
DATE �!
SITE ADDRESS �
TEIIS ..�PPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
5UBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERNIIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFF'ECTIVE 2-19-09
O O��"ITTER
N
YOUR E-MAII.
C011IP.=1NY N.�4E: v�anva� �a � �cau� �y .r . ... ................. .-
CONT.�CT PERSON: y
STATE LICENSE # F 17_R7d_i� DATE
ADDRESS:
PHONE
F;�;IILl' ❑ TR�O FAhiII,l
� NE�L' �2EPLACE�•tENT
DETAILED DESCRIPTION OF WORK
FAX
❑ TOWNHOUSE
❑ ?.LTERATIONtREMODEL
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STATE ZIP
FEES ARE BASED ON S10.00 PER FIXTUI2E, EXCEP'�,WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBIIi OS EACIi BEIAVI�
Equipment Instalkd MEG: � MODEL: SIZEIBTU
MFG: � MODEL: �� SIZF/BTU " ��` �
MFG: MODEL: SIZEBTU
�!C 523.00 _FIREPLACE (GAS) S 15.00 GAS Rt1NGF/OVEN SI0.00
AIR TO AIIt EXCHANGEER SLS _FIREPLACE (WOOD) 535.00 NEW GAS GRILL 510.00
BOIL.ER Si5.00 FURNACE 535.00 GAS I�iIT HTR 510.00
CHIA�IIQEY LINER S 10.00 _GAS DRYER 510.00 POOL HEA11?R E35.00
DUCT WORK 510.00 GAS PIPING 510.00 VENTII,ATOR S15.Q0
�"'�� ��' THIS IS AN �PPLICAT[ON FOR A PERMIT-NOT VALID UNTTI. PROCESSED
I hereb_y appiy far a btulding permit and I acl<no�a�ledge that the information above is complete and accurate; that the work �vill be in
confocmance �vith the ordinance and codes of the Citv of Fridley and �a-ith the Minnesota Construction Codes: that I understand ttus is
not a perniit but only an ap cati o a pe ° rk is not to start with t a perniit; that the wo c�till be in acco ance �vYth the
approved plan in the case f all � h r q es #ev ew and approval of p . - I � J��
SIGNAT'URE OF �PPLICA TI,�fE � � t
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977