P - 48437'�uilding
�nspections
763-� 72-3604
763-�02-4977 FAX
D1TE �� 1c�"�1 _ .�� ,
SITE ADDRGSS �
THIS APPLICAN`PIS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
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EFFECTI V L 7-1-2010
��r f'd+'1 7...i✓
YOUR E-MAIL ADDRL-SS
❑ OWNER �'CONTRAC�OP
NAME: a� "� W 0 U 6� � b
ADDRL-SS: �OI !)��✓ �'u� p�/
PHONL: I b3 .� �T 1 J 4�-i J..
Permit No.:
Received Bti�:'' !�'�� " i
Dat��: � r ��
CITY ,Cl2� (�.., STATE�9 N ZIP �"J V,�L.
COMPANY NAME: r l. l_v ��/ �� � �� L�.� �LC �
CONTACT PERSON: C� r�S f�.L-P1�
STATG LICENSE # EXP DATE
ADDRESS: 0 a� � K�-� "� �• � E CITY ��� b 1 �t STATE f'[►-�ZIP`j`� y3 Z-
PHONE � l,S '%S 4"' �� g� PAX
�S SINGLE FAMILY ❑ TWO FAM[LY
❑ NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK lh
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
1_t. r,.. ..L �� /L ��v10iC�t C*'
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANCTAL J 2006 ASHI2AE HANDBOOK
Equipment Installed MFG: C G-IZ-�2i �wv MODEL: o��i 4����'�" SIZEBTU eZ-%v +"'1
MFG:
MODEL:
SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIRTO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 FiIRNACE $35.00 GAS iINIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WOR[� $] 0.00 GAS PIPING $] 0.00 VENTILATOR $15.00
Nuraber of"fixtures @ $10.00 x $10i60 = `,S
Number af f Ytures @$15.00 x$15.00 =`.S
Number of fixtures @ $25.00 � x $25.OQ = `.> � �-� �' `'''
Number of fixtures @ �35.00 x $35.00 = $
. �
State Surchar�e — $ 5.00
�, , .: `""'. `'� � . , +� , �
(MIrTIMUM F�E �40.00) Total = $ �•-.��,�"��r ``� �' • `' ` � �
, .,, .� THIS lS AN APPLICATION FOR A PERMCT-NOT VALID UNTIL PKOCESSED
I hereby apply ding 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 Minnesota Construction Codes, that I understand this is
not a permit but only an application far a, ermit and worl< is not to start without a permit; that the worlc will be in accordance with the
approved plan in the case of all work which quires�view and approval of plans.
SIGNATURE OF APPLICANT ��/t.l a , ,p PRINT NAMG_ C"� i' l3 ►< a.,p �p /�AT� y J� �-^ L�
APPROVAL INSPECTORS SIGNATURE
`° PL�ASE NOTE: SEPARATF
DATE
City of Fridley
uilding Inspe�tions Department
64�1 University Avenue NE, Fridley, MN 5�432
763-572-3604 FAX: 763-502-4977
/
AL` WORK
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