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76�—�72-3604
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SITE ADDRESS �
THIS APPLICANT IS: (�' �.�
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YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
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NAME: �1 c. (, � %7� e �r � � —
ADDRESS: (F (, ;:� o f2. 0- ���o a�.a� �,; CITY ��. i K? ( L STATE �"1 N ZIP � s Y31,
PHONE: ? 6 3� 4F �('7 � S a- a�-
CON'TRAC'i'OR COMPANY NAME: � c v. v Ct �i. � � t{-�'(��
SUBMIT A COPY OP CONTACT PERSON: C ti r-r .� � n
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WiTH ,qDDRESS: �d �/ U Tj(} �,� S� � E CITY �t� 1 ro l. . STATE,� w ZiP S�1 �3 �,
APPLICATION pHONE ? 6 3-- '1 S� � d l 4 S FAX
PERMIT TYPE
TYPE OF WORK:
FAMILY ❑ TWO FAMILY
C7 NEW I�EPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �nsd+e (( %�r-�� �a� Fr � cr �a �,, �n s�.�-b
FEES ARE BASED ON 510.00 PER FIX'TURE, EXCEPT WHERE N01'ED. FiXTURES: (INDICATE TOTAL NUIYIBER UF EACH BELOW),
PROVIDE HEAT LUSS CALC'S PER MANUAL J 2006 ASHRAE FiANDBOOK
Equipment Installed MFG: !1-0';� N t`- t MODEL: .I,a � t�Sv � �l�! ��-- SIZFJBTU
MFG: MflDEL: SIZE/B'TTJ
� MFG: MODEL: SIZEBTU
_A/C $25.00 i FIREPLACE (GAS) $iS.Oa GAS RANGFJOVEN S10.D0
AIItTO AIR EXCHAI3GEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOII.ER $35.00 _FURNACE $35.00 _GAS LJNIT HTR $10.00
CHI1vIIJEY LINER $10.00 �GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 ! GAS PIPING $10.00 _VENTILATOR $15.00
THIS IS AN /�PPLICATION FOR A PERMIT-NOT VALID UNTIL PROCGSSED
I he:eby apply for a building 7ermit and 3 ac;rnowledge that the information above is complete and accurate; that the worlc will be in
conformance with the ordinances and codes of the City of :'ridle;� and with the Minnesota Construction Codes; that I understand this is
:�ot a permit out only an application for a permit and woric is not to start ��vithout a permit; that the wor3c will be _n �ecordance with the
aporoved ;�lan in the case of all �.vorlc y�r�iic'.i requires revie�N and anprovai oi plans.
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