P - 42832Building
Inspections
763-�72-3604
763-502-4977 FAX
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EFFECTNE 7-1-2010
DATE � U- %-' �/ YOUR E-MAIL ADDRESS
SITEADDR�SS I��� 1 1 tii=+iSSt(J�il S� f•).'^^', r��C���
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
Permit No.:
Received By:
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PROPERTY NAME: �j' t l I Di-� `� �'^
OWNER/ ADDRESS:�,� �. I /� t'3� �� �! ¢?�t Sl' U,+C CITY F�:I i+_ ' STATEE' � ZIP �'' �-3'!-
TENANT
PHONE: �L-� -- ;S %� � 7�17 �l
CONTRACTOR COMPANY NAME: Lv � C. • � � L'� �—�
SUBMIT A COPY OF CONTACT PERSON: C� �� �.1 {'nt, 0-,P i° -
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: � a�� 1 1��'� �t ° bu � CITY rtR t h( L. STATEPI � ZIP 5 3�� '�`
APPLICATION pHONE '] 6� 7S `f d I�l �! FAX
PERMTT TYPE
TYPE OF WORK:
.�aSINGLE FAMILY � TWO FAMILY
❑ NEW �1,tEPLACEMENT
DETAILED DESCRIPTION OF WORK ._i--
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDIGATE TOTAL NUMBER OF EACH BELOVh
PROVIDE HEAT LOSS CALC'S PER MANUA J 2006 ASHRAE HANDBOOK a
Equipment Installed MFG: ��� MODEL: �'� O� SIZEBTU (O � V v C
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 _FIILEPLACE (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 UNIT HTR $10.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 _GAS PIPING $] 0.00 _VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acicnowledge 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 work which requires review an�approva�of plans.
SIGNATURE OF APPLICANT ��
APPROVAL INSPECTORS SIGNATURE
City of Fridley
�uilding Inspections �epartment
6431 University Avenue NE, Fridley, MN 5�432
763-572-3604 FAX: 763-�02-4977