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Ins�rections
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763-502�4977 FAX
Frvm: 7635720164 Page: 2/3 Date: 9l21/2011 12:25:57 PM
�CHAIVICA�, ( P�r�'it
��I�IENTIA�, APP��C.A.�'�U�T Received By:
. �'��`X OF FRITILEY Date 1��-
���CT1VE 1-1-241D
XbUR E-MAIL A17b[t�SS
SITE ADIP�SS • -
TFIIS APPbICANT IS: 0 UWNER� �CONTRACTOR
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TENANT
C4NTRAC'T�R j CON[pANY
SLJ��FTA CO�Y pF CONTACT PEELSDN: FI+OXD �T��WICIG
'YO�JJR STA?'E STA7"E LICENS� �1_ __ _- -- _ E3tP DATE
iiCENSBWITH p�p�S�:�Z21 University P,ve, N.�. Crrv Fridley STATEMN ZiP 55932
,4�pL�GA'(iQN PHONE 763-572-0459 Fnx763�-572-0164 � �
PERMIT TYPE i���'LE FAMTLY ' D TWO FANiILY
TYPE O�' WQ�tJ.(; I O NEW �REPLACEMENT
DETA'1.�.ED AESCR�I'TIO1V bF WORK
CJ TOWNHOUSE
❑ ALTERATIQNlREMQA�'�
��S AR� SAS�O C1N 51:6.00 PElk FIX'TIlRE. &XCEP'i' WHERL NOi�. F1X'FURE&: ([�+�DICATE TOTAL Ni3M8Ett OF �ACH SELAW)
�"ROYIb� El�+�T LbSS CA.LC'S P�R MANUAL J 2006 A^aHRA� HANDBOOCf.
Equipment Installed tvIFG: Mp15P.a,.: ��Z��
MFO; � MODfix.; ��� SiZ�T'U __,��r�_ r�r��
� �-~
�C�: _ .... MQdEI.: S[ZEiBTiI
_NC 525:00 �FITiEPLACE (Qq$) S15.Ob ,_,_,GAS RANGEJdVEN SI0 00
:� T� A�R �XGW�GEER S15 FIR��I.A,GF (WdpD7 535.00 NEW dAS C,RILL 510.00
_HOILER 535.00 �FURNACE �35:Q0 ,,,,,`GAS UNET HTR S 14.40
CFitMNEY LINER S1Q.00 _GAS DRY�R S} 0.00 �POQL HEA7ER �35.UU
„"'AVGi' W4RK 510.00 _ lGAS PIPfNC3 510.00 _.__ .. _... __vENTILATOR 515:00
TIiIS iS AN APPLtC.q,7'1dN AOR A PERMIT-Np'C VALID UNTIL Pitt)C6g5ED
I haraby apply far a bailding perrs�it and I acknowlcdge that kha in%rmstAbn abavo is comptcte and accurste; that the work wili be in
co��ozaz�a�ce with the ordin ces and eodes af the City of Fridley and w�th the Minnesota Constructivn Codes; that � undorstand this is
not a permit but a�ly an ap 'catioz� far a perrnit �d wvrk �s not to start withvut a permic; ehat tk�e work wi11 be in $ccordance with chc
approved plan in the case of I wor�C-�ra��s review and sppz�oval af pla�s• ., .i n_ _ _.
SIGNATURE OF APPLICANT
DA
City of Fridley . a
� B���di�g Iasp�ct�o�ns Dep�rtar�ent
643 � University Avenue �E, Fridley, MN SS432
7b3-S72-3644 k',AX: 763-SQ2-497'7
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