P - 44909�3uilding
Inspec�ions
763-572-3604
763-502-4977 FAX
DATE
SiTE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
�
RESIDEI�`I'I�AJ�APP�ICA'1�I�N
CITY OF FRIDLEY
EFFECTivE �-�-aoi�
YOUR E-MAIL ADDRESS
1�'7 OWNER ❑CONTRACTOR
iti�o.:
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�tr'i��i��!- �
NAME: / �/Q/111� 7 �< �JQj�N 7UN
ADDRESS: !�� �� c.Cl/1/✓G Y �'ijEE%' CITY �R,��� f/ STATE��ZIP , Sy�3�
PHONE: /�j�— S7y � ��7�
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LTCENSE # EXP DATE
LICENSE WITH ADDRESS: CITY
APPLICATION
PHONE FAX
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: �� NEW L�REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �EPLACE �(J�q�}iFJq7E�
TATE ZIP,
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAJ�, J 2006 ASHRAE HANDBOOK P/' �D ��`F/ t' ?
Equipment Installed MFG: 7t(C%'�M (jA)� MODEL: �O V �O SIZEBTU �7 � J �
A/C $25.00
AIR TO AIR EXCHANGEER $15
BO[LER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $ I5.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZEBTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERM[T-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 Frid(ey 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 work ich u'x s v ew and approval of pla�
ns.
S[GNATURE OF APPL[CANT '✓�C�I � '^t� PRINT NAME I 1I� /" ��/ O/�ATE �� I
APPROVAL INSPECTORS SIGNATU� ��� � DATE \n ( /
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977