P - 44553From: 6506556633 Page: 2/2 Date: 3/30/2011 'I0:25: T 4 AM
From: Officel Fax: (800) 560-6011 To: Fax: +1 (763) 502-4977 Page 2 of 2 3130l2011 10:22
Building MECHANICAL Pe►��t No.
Inspections RESIDENTIAL Al'PLICATION Received Sy:_
763-572-3604 CITY OF FRIDLEY ' �
763-502���7% �.A.x EFFECTIVE 1-t-201 t ��e �� �, f7
DATE � 'J
Sl'TE ADDRESS (�
THfS APPLICANT IS: 0 OWNER
PILOPERTY ���:_�
QWNER/ ADDRESS: �
"T�NANT
PHONE� ��
CONTRACTQ�R
SUBMIT A COPY OF
YOUR STA'FE
LICENSE VVITkI
APPLICATION
PERM1i1T i'YPE
COMPANY NAME:
CONTACTPERSON�
STATEi.iCF.NSF,1? ,
SINGLE FAMILY
YOUR E-htA1L
❑ TWO FAMtIi,Y
TYPE OF WORK: �� NEV�' � D[REPLACEMEN'I'
/�
DBTA[LED DESCRIPT101� �OF WORK '�
FAX
❑ TOWNHOUSE
❑ ALTERATTON/REMODE.L
T
FEES AItE SASED ON S1Q00 i"ER FiXTUR@, EXCF,pT WHERE NO'I'EA. �'IXT[;RE3: (1NDICATE TOTAL IVUMBER OR EACH BELUVI�
PROVIDH HEAT LOSS C�►LC'S PER MANCTAL J 2006 ASHitAE HANDBppK,
L-quipment Iostalled MFG: ' MODEL: SIZE/BTU
MFG: �TODEL: SIZE/BTU
:�1FG: '�tODEl.: ST7E/BTi:
A!C 525.00 FIREPLACE (GAS) 515.00 GAS RANGFlOVEN $I0.00
.�A]R TO A1R EXCHANGEER S15 _FIREPLACE (WOOp) $35.00 T,NL•W GAS GRILL 510.00
BOILER 535.00 �FURNACE $35.00 GA5 iJiVIT [-IIR SI0.00
CHIMNEY LI1�ER $10.00 GA5 DRYER $10.00 �pQpL HEATER 535.00
�UCT WO�RK$1�,l��� �GAS PIPiNG $10.00 _ _VENTILATOIZ$15.00
THIS IS AN APPLICRTION FOR A PBRMTT-NOT VALID UNTIL PROCESSED
1 hereby apply for a building permit and 1 acknowledge that the 4nformation above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the Clty of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and �vor ' ot to start without a permit; that the work will be in accordance with the
approved plan in the case of • bich uires r d approval of plans,
SIGN.4'CURE OF APPLI NT PRINT NAME �/' � pq-rg � �(j ',�,/
..,..�..,, - - --...___---- --- — _ �. A (l w h ,in . . "
City of Fridley '
i ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX; 763-542-4977
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