P - 35077Building 1V�EC�iANIC1�� permit No.�
Inspections ��i ���EN�'IA� A.�'PL��:1�.�'ION Received By: �
763-572-3604 ��T� OF FR�DLEY Dat���l: � � � � � - � ` -
763-502-4977 FAX EFFECTIVE7-1-2010
DATE r%— I i- l� YOUR E-MAIL ADDRESS
SITE ADDRESS �3� � � �O ['tt�� � �-✓� ,i� � C r �-1 � ( �x
THIS APPLICANT IS: ❑ OWNER T�ONTRACTOR
PROPERTY NAME:I I Q �C �,� C� �+'► � c.I�r �� S �'�
��E� ADDRESS: ��% �o F"��o �r L2 �'1 �/� ^ K�V NCITY �k,t C i�.,. STATE hl � ZIP S S� °1 �
TENANT ` �1
PHONE: rI b�-• J%�• 3, U-1
CONTRACTOR COMPANY NAME: 2( v o.✓ l.l � � t'� �-� � L F 6')
SUBMIT A COPY OF CONTACT PERSON: C� �� S 12 ..-p �
YOUR STATE STATE LICENSE # � EXP DATE
LICENSE WITH ADDRESS: l/�� V ' t��`^ o� �C CITY !' 17� STATEM"'�ZIP S'S�i
APPLICATION pHONE �I l 3 Z S� o�� � 9 FAX
PERMIT TYPE �GLE FAMILY ❑ TvVO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ,�REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK .�Y� 3�A t 1 2�( e-�..� ��., � JQ t 2 t,6 ✓Ld t� t csv�.��✓
FEES ARE BASED ON 510.0(i PER FIXTCTRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
EquipmentInstalled MFG: i.'�.�+-+�ti MODEL: Zy14 Clb 3�l( SIZEBTU o1-Ta ►'i
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
�A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 FIItEPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
,_BOILER $35.00 _FURNACE $35.00 GAS LJNIT HTR $10.00
,_CHIMNEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
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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 wili 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 a11 work which requires review and approval of plans.
SIGNATURE OF APPLICANT ���1.41 ��-(c� � PRINT NAME C� �- � > �/Q� DATE � �� 1 � �' � I
APPROVAL INSPECTORS SIGNATURE DATE
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City of Fridley
Building Inspections Department
6431 Uni�ersity Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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