P - 47280From: unknown Page: 4/4 Date: 8/24/2011 10:09:06 AM
Building MECHANICAL F���t rt�.:
Ins ectxa�as "
� RE�IDENTIAL AP�LXC.A►.�'�ON Receiv�d By:
�'63�572-3604 C�x'�X �X+' X+'��Y�EY �ate ��� � �1 G 2
763,502�4977 FAX
EFF�crrvE t-�-zot i
DATE � �~ �'C "' � � qOUR E-MAIL ADDR.ESS ,�,� '� �' � rJ 1"t��.K'� E �'��fPi � L�iI� �
3PfEADDR]ESS t ' �', ��
THIS.APPL[GANTiS� ❑O'4VNER �ONTR.ACTOR
OWNER/
TENANT
C�NTF.AICTOR
SiJBMYT A COP�' Op
1'OUR S�A'x'T
iTCL1+TS� �iT�Y
APP�.ZCt#T10�1
��XtMXT TYP�
xxa�� oa� �va�r��:
)ETAILED DESCRI]
PIiONTs:
GQMPANY NA�;
CONTAGT P8R$p�f;
STAT� LiG''�I+igE # �
ki�O�iE
FAX
�XY l?AT�E
y�snvGLB FAI�II.Y O�WO FANI�,X O TOWNi{OUSE
C7 NE'GV' ❑ KL'PLACEMENT �ALTBRATION/�MOLIEL
OF WORK
'��+ ZIP.
Y�ES ATt� BA5� QN' $10.00 Y�Yt �'IXTTIRE, E?CCEPT WHERE NOTED. FI7CT[JxtT�$; (�1vpx�;�� TOTAL NTl14f13�R d�' EACH $ELUV1�
pit0`VrifB �AT LOSS CALC'S P�R MAIYLfAL J 200G ASHiiAE HAl�IDBppK.
Equipment Installecl Mr(3: MODSL: S��g�
MFQ:
M�bEL: 31ZEBTU
MFQ: MOD.SL: _,__� 31Z6/$TU
_N� S25.OQ FIREPLACE ((�AS) $15.00 �GAg �GEJOVEN $18,00
,�AZR T4 AIIt B7CCFiANGEBR S1S FIREPLAGE {WOOri) $35.00 ,_,,.NEW GAS ORII.L $10.40
.S�ILP,�t S35,OU FURNACE $35.00
_CHIMNRX ���t 510.00 _C�AS D1tYER $10.00 , _G�#S [Ti�i�' HTR $10.40
,.YAUC'� W0� $10,00 �POOL HEA,'TS� 535.00
QAS PIPINCr $ i 0•00 VFSNTILA,TOR Si 5.00
Y Y1 1. 7 wr _.
TEII3 IS AN APPLICATION FOR A FERMY'C-NOT' VAT.ID UNTIL PROC&SSED
I her�by apply for a buiiding permit and I acknowledge that the infarm;atxon above is cornplete and accurate; ti�at the work will be �n
ctmformance with thc ordinances and codss of the City of Fridley and with the Minnesota Construction Codes; that I understand ihis xs
hot & pemllt but o�lly sn 8,ppjiCati�n for a permit and work is npt to stm'f wxtk►UUt a permit; that the work �iil be in accordance wifia the
appro'Ved plen in thC csse of �vark ���qu' es'r��w and approval o�pl�r►s.
SxGa`1A'1't3�i,6 OF AI'PJ..SCA;NT
� � _,
� City of �'rydle�►
Buildr�ng Inspectians Depart�nnex�t
6�31 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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