P - 48204�uildin� l�t/�����1lT����
Inspections �����I��'�,�.� �.�'��,���.�'��,1�T
763-572-36U4 ���� �� �����
76�-J�2-�'9 /7 Ff�i C-FFECTIVL7-1-2010
DATE 1 ! � �{ -
SITL- ADDR�SS
THIS APPLICANT [S:
PROPERTY
OWNER/
TENANT
YOUR L-MAIL ADDRESS
❑ OWNER �CONTFtACTOR
NAME: 0 A''1
ADDRGSS: /5 SI O I"'�t SLdi ��Ai � N� CITY F+�+Yl)
PHONE: �J�3- a.z►- as5�
Permit No.: ';,ZQ' �'j' �
Received B}�:
���t�:��` �s :� -,
STATL- KN ZIP,
CONTRACTOR COMPANY NAME: ��ll��v C�1 'C. C� �► �.�� 1"'(l.� �-I
SUBMIT A COPY OF CONTACT PERSON: C�r�� f2��1�
YOUR STATE STATE LIC�NSE # EXP DATE
LICENSE WITH ADDRESS: O� � � A-�^ S�� uE. CITY �k-�'�L� STATEK'^�ZIP
.qPPLICATION pHONE '1 �.3 '2 �� oll Q �/ FAX
PERMTT TYPE
TYPE OF WORK:
�SINGLE FAMILi' G TWC PAMIi,Y
❑ NEW �REPLACEMENT
❑ TOWNHQUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK _�NS{,� �( r2..��pl+.-�-<<'it,-v6 F�u.�c.�� «-
FEES ARE BASED ON $10.00 PER FIXT'URE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MAIVUAL J 2006 ASHRAE HANDBOOK
Equipment Instal led MFG: (1.. v v O MODEL: � G I� C' D��MA � SIZE/BTU C� V�
A/C $25.00
AIR TO AIR EXCHANGEER $ l5
BOILER $35.00
CHIMNEY LINEA $10.00
DUCT WORK �10 00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
�FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZEBTU
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
Numhero£fi�ctures Q �.10.00 '��� ' x�$1�D.00 = $��' � � � � � � �
Numbez of fixtures @$15.00 x$1 S:DO =$:
Number af.fi�ctures @ $25_00 x $25.00 = $
Number of fixtures @ $35.00 '� x $3.5.00 = �` 3 5• � �
'State Surcharge;= $ 5'.00
(1ViINTMiTM"FF,E :�40.001 Total = $ �b� O�
THIS IS AN APPLICATION POR A PERMIT-NOT VALID UNTIL PROC�SSED
I hereby apply for a building permit and I acl<nowledge that the information above is compfete and accurate; that the worlc will be in
conformance with the ordinances and codes of the City of Fridley and with tl�e Minnesota Construction Codes; that 1 understand this is
not a permit but only an applicati � for a p it nd worl: is not to start without a permit; that the worl< will be in accordance with the
approved plan in t11e case oi' all worl< l�i reqtiir,�s review and approval of plans.
SIGNATURE OF APPLIC,INT n,�I�Ct- PRINT NAME 1 L. r t J G_..n A DATL- � �_�^ �I
APPP�OVAL INSPLCTORS SIGNATIJItE DATL �/ v/ �
PLE.�SE NOTE: SEPAR,aT� P ARE -QU ,D FOR I3UILD[NG, ELECTR CAL AND N[ECHANICAL �VORl<
�l� OI �II'Il(�le�
uilaing Ynsp�ec�ions �ea�r�pnelat
�] Universin� Avenue NE, Fridley, MN ���32
763-�72-3604 F'AX: 763-�02-4977