P - 46516Building l��C�N�C��
Inspections ����i �'�'��, �������'�'���
�6�-s�?-�6a4 ���'� ��' F���I.'
76J-502-4977 FAX - EFFECTIVE7-I-2010
DATE � I� � a- Z I
SITE ADDRESS �
THIS APPL[CANT IS:
.c�o �
❑ OWNER
YOURE-MAIL ADDRESS
N E ��2 � o (-a
%�CONTRACTOR �
Permit No.:
Received B}�:.
D��'K�t�
PROPERT'I' NAME: (�A e.�I Q. AI�. �S 0Y1
OW1�ER/ ADDRESS: 3l$ uU,4 � �-�• CITY F(Q.11O�� ' STATEM� ZIP
TENANT pHONE: Z�� g�F � 3I Q
CONTRACTOR I COMPANY
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CONTACT PERSON: /� 1,� r c1 12.Fp P
SUBMIT A COPY OF --�-r-
YOUR STAT$ STATE LICENSE # EXP DATE
LICENSE WITH ADDRESSt�e�-Q b ii 4-i `'� S�' �� CITY. Fv�i �I � STATE��"' ZIP � f w3�
�.�PPLICATION pHONE �<3 �I S't o1 t Q q FAX
PERMIT TYPE
�rE oF woxx:
�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �REPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK ZYtS�A l� IZ�,i,p �t-C�rt�,,�� ��+�.�+Z �► � er�-
FEES ARE BASED ON $10.00 PER FIX3'[TRE, EXCEPT WH�RE NOTED. FIXT[7RES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT L033 CALC'S PER MANU J 2006 A��AF. $�jj�v$Qp$ Q� O 6
Equipment Installed MFG: U P MODEL: �{� (� 61 � SIZEBTU
A/C $25.00
AIR TO AIR EXCHANGEER $15
_BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $] 0.00
MFG:
�����A
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE {WOOD) $35.00
,�FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $] 0.00
SIZEBTU
SIZEBTIJ
_GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
_POOL HEATER $35.00
VENTILATOR $IS.00
THIS I5 AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED '
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the worlc will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that [ understand this is
not a permit but only an application for a permit and worl ot to start without a permit; tl�at the worlc will be in accordance with the
approved plan in the case of all work which re ' es rev�a approval of plans.
SIGNATURE OF APPLICANT , PRINT NAME l� {� ni �� Y�*- �,r� DATE ,� �' � d�� �
APPROVAL INSPECTORS SIGNATURE _
./4--1�
' City of Fridley
uil g Inspec�ions �epartment
643 niversit�� Avenue NE, Fridley, MN »432
763-572-3604 FAX: 763-�02-4977
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