P - 48665Building 1V�E��ANI�A�
Inspections �SI��N��L �,p�'�,I�ATI4N
763-572-3604 ���.� 4� ������
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE � 7 ��[ 7 _
SITE ADDRESS _�_
THIS APPLICANT IS:
PROPERT�'
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR �-MAIL ADDRESS
❑ OWNER �ONTRACTOR
NAME (,.y (G �(L/`N�L/�-lQ
ADDRESS: 5 �'✓Yt� CITY'
PHONE.�7 �Q_��77 �+O SS�
Permit N
Received By:
�,�; �� a.
�
TE ZIP
COMPANY NANIE F�
CONTACT PERSON: C�i �� /GC�(�?P
STATE LICENSE # EXP DATE S �..f
ADDRESS: G�{7 D iYIC�(�_�-r']� � �� CITY �I(�/ STATE �/ZI� �
PHONE lG��%S�i�_ a l.; 4__ FAX ��l � S�I— �'O �
❑ SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �PLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANiJAL J 2006 ASHRAE HANDBOOK
Equipment lnstalled MFG: MODEL: SIZE/BTU
��'C'�r25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $] 0.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
F'IREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
!�`URNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZEBTU
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $]0.00
GAS LTNIT 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 I understand this is
not a permit but only an application f 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 wor�hi,�'i qu es�iew and approval of plans. _
SIGNATURE OF APPLICANT
AL INSPECTORS SIGNA
�/ City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
0
DATE 7 � S� � �
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