P - 41767Building ��'i,,�`��N���� Pern7it No.: � -(}'
Inspections �����i �T'�'�,��, �,���,���,�'���,T Received By:
763-572-3604 ���'� �� ������ ��e��
763-502-4977 FAX EFFECTIVE7-1-2010
DATE � ` �%-- � / / YOUR E-MAIL ADDRESS
SIT� ADDRESS C�f � �/ l'%4 ✓�'�'�'+� ✓ N� t"' �Q / d I r.-,i
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NAME: .J b h v� Lw� p u C(. �p ►�;t�1
�WNER/ ADDRESS: $ I 1 d V l+Q.'�" a�+ Q✓ (� � CITI � STATE H1tJ ZIP
TENANT pHONE: -?b3 - ; 7 ( - 5 `l'f �.. -�
CONTRACTOR COMPANYNAIvIE: I�1�lt�✓ C..�, o�l L�-�, �Il-�� –
SUBMIT A COPY OF CONTACT PERSON: _�'�. �/ r� 1%Z.1���
YOUR STATE STATE LICENSE # EXP DATE _
LICENSE WITH ADDRESS: �°l 9� � 0-t-ti c�b Nk CITY F►�. �'�� �. STATE�,f �ZIP SS�3�.
APPLICATION pHONE "7 �3 ? s� a r 9 9 FAX
PERNIIT TYPE �SINGLE FAMILY ❑ 3'WO FAMILY ❑ TOWNHOUSE
TYPE OF WORK' � �W ��PLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �;�-�,01 � ✓<< �I Q-��h. � ,-. � �t^'� '^'° � `-' _
FEES ARE BASED ON $10.00 PER FIXT[7RE, EXCEPT WHERE NOTED. FIXT[JRES: (INDICATE TOTAL NUMBER OF EACH BELOVh
PROVIDE HEAT LOSS CALC'5 PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: L'6� ��-� �-�-- MODEL: S� C TA d�� SIZEBTU � 0 U U
MFG: MODEL: _
MFG: MODEL: —
A/C $25.00 _FIREPLACE (GAS) $I5.00
_AIR TO AIR EXCHANGEER $I S FIREPLACE (WOOD) $35.00
_BOILER $35.00 �FURNACE $35.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00
DUCT WORK $10.00 _GAS PIPING $] 0.00 _
SIZE/BTU
SIZEBTU
_GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS iJNIT HTR $10.00
�POOL HEATER $35.00
�VENTILATOR $15.00
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 will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that 1 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 ^hich req � es review and approval of plans. _
SIGNATURE OF APPLICANT �'�( e _ �
APPROVAL INSPECTORS SIGNATURE _�
il
DA
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 5�432
763-572-3604 FAX: 763-�02-4977
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