P - 36938Building
Inspections
763-�72-3644
763-502-4977 FAX
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DATE C-' ��f -• G�1 YOUR E-MAIL ADDRESS
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THIS APPLICANT IS: ❑ OWNER �ICONTRACTOR
PROPERTY
OWNER/
TENANT
C�Zi�Y Y�7:Ii1��Ci13
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMTT TYPE
Permit No.:
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NAME: A nA {y,�e \„�3�r� p_s a�. �-s�
ADDRESS: �(. b �— l b�-�c.�- S� �+ E CITY �rt r __STATE f�, ,�J ZIP SS �/�L
PHONE:
COMPANY NAME: /G �, � , e �
CONTACT PERSON: C�. � � ��
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STATE LICENSE # EXP DATE
ADDRESS: Rc� C1 __ T� �_ -� __ Q b.__ N E CITY I'l � i t,� STATE�"« ZIP� ��
PHONE 7 6 3 7 S� d I�t �_ FAX
�rYrE oF woRx: I ° NE`�'
QLY ❑ TWO FAMILY O TOWNHOUSE
,eJ`REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK Z�S-�� �� ✓'L` �� a-�•"��-� � �« 2-� p`��'�
FEES ARE BASED ON $10.00 PER FIXT[JRE; EXCEPT R'HERE NOTED. FIXTIJRES: (INDICATE TOTAL NUMBER OF EACH BELOR�
PROVIDE HEAT LOSS CALC'S PER MAN{JAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: ' SIZE/BTLJ
MFG: MODEL: SIZEBTU
MFG: MODEL:
_A/C $25.00 _FIREPLACE (GAS) $15.00
AIR TO AIIt EXCHANGEER $15 _FIItEPLACE (WOOD) $35.00
_BOII.ER $35.00 �FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
DUCT WORK $]0.00 GAS PIPING $]0.00
SIZE/BTU
GAS RANGE/OVEN $]0.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS 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 work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all wor. which requires review and approval of plans.
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SIGNATURE OF APPLICANT � ��. /"�. � � ( � A.,� c� PRINT NAME �- �'` rt � � �`.�i t� . DAa'E � °' � � "' � �
APPROVAL
DA
��"t%'' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 5�432
763-572-3604 FAX: 763-502-4977