P - 45300�uilding ���;�����; ��, Permit No.: t�
�nspections �����i N'�'�� ,������'��'��� Received By. -
76�-�72-3604 �:I�� �� ������ �ec� : . <� ��
763-5�?-4977 ri�x EFFECTIVE7-]-2010
DATE rI `�• • l 1 YOUR E-MAIL ADDRESS
SITE ADDIZESS ��1 'a i{ l l��t � u� y ��'`t v�.. � iE' P�^ �>, � t'", N '�� S �.{ 3.1--
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY NAME: �.� ..� � Gti ���.-� �- i t n_„�
OWNER/ ADDRESS'� ���I � �"% � I �: � *, lJ� CITY � P'.-�.(� �'� - STATEfi� � ZIP � � �� .�i a.
TENANT -
PHONE: % i,.'� ' �l � "'�'- :i Z �
CONTRACTOR COMPANY NAME: � f ^ t- � 1�� �"�i�- ��..1
SUBMIT A COPY OF CONTACT PERSON _� r�-y v�C��
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS:�j i: (`"% 9-t�-i S� t-'{>'': CITY F✓Lirl%cc� STATEt�"JZIP �� .a�.1_
APPLICATION �
PHONE � i,-� `� S a� i�, t�� ' FAX
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �tEPLACEMENT ❑ ALTERATIOIVlREMODEL
DETAILED DESCRIPTION OF W ORK Zr, �(� ( t ,f�tl�( � r,,...,,,,� �� ta a vt�s t c. �- �� 2 C.s� £� ��' ����''
FEES ARE BASED ON $10.00 PER FIXTURE; EXCEPT WHERE NOTED. FIXTURES: (INbICATE TOTAL NUMBER OF EACH BELO�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: r' A��+� MODEL: �i.S� 13 A� DN10 6 U • SIZEBTU b �. � � �
MFG: � v' °� o c^'k MODEL: I��(3 e.! fi 0�-�{ SIZEBT[3 a�U '��
MFG: MODEL: SIZEBTU
� A/C $25.00 _FII2EPLACE (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 LTNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $]5.00
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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 worl: will be in
conformance with the ordinances and codes of the City of Fridley and with the Mannesota 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 work wh� requires review and approval of plans.
SIGNATURE OF APPLICANT � �' �'�" ^a ''-"�> PRINT NAME �-'.. �-^. �'' ' � � �- '� "' DATE �' �� �I
APPROVAL INSPECTORS SIGNATURE DATE t �
PLEASE NOT�": : SEPA.RA'TE P� �AR.�:R:EQUI, -BCiILDlNG;'E�:E `ND NIECHANICAI� ,WtJRK. ''
City of Fridley
Buildina Insneetions Department
6431 University Avenue NE, Fridley, MN 5�432
763-572-3604 FAX: 763-502-4977