P - 48300J
. .
Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-s�2-3604 �ITY OF FRIDLEY
763-502-4977 FAX .......�....�.� . . ___.
DA� r� � ��z-
ST['E ADDRESS ��
TfiIS APPLICANT IS:
PROPERTY
OWNER!
TENANT
SUBNIIT A GOPY OF
YOURSTATE
LICENSE WI1H
APPLICATION
PERNIIT TYPE
�rE oF wo�:
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
co��
Permit No.:
• - -. :
�+1� '
�.,�_���-�� , ��1.�T. �
�
STATE LICENSE # �� L�� �N rJJ:� EJ� DATE
ADDRESS: CITY STATE ZIP
PHONE — FAX .
FAMILY � TWO FAMILY
� NEw �REPI�ACEMEIVT
OF
❑ TOWNHOUSE
❑ AL'IERA3'ION/REMODEL
FEES ARE BASED ON S19 08 PER FffiTIJRE, EXCEpT yVHERE NOTED. FIRTIJRES: (INDIGATE TdTAL NUMBER OF EACH BELO�Vj
P1tOVIDE ftEAT L06S CALC'S PER MAN[T �j� .ri.SggAE gANpBppt{, ,�[�� %�
Eq�riPaneettnsmlted MFG: ��'fc.M�} MODEL: ���3Z!���"��'O�SIZEIBTUU���
MFG: Q.�� MODEL: �;�'1v�� SIZE/BTU s`—TV` \
MFG: MQDEL.:
�AJC 525.00 _FIREPLACE (GAS) St5.Q0
n� �ro nm �ccxaxcE� a� s �rr.acE �wwooD� s3s.00
BOILEIt 535.00 �FURNACE 535.00
CFIIIvIIVEY LINER $10.00 _GAS DRYFat $10.00
IWCT VPORK $10.00 -- GAS FIPING SIO_00
�
SIZEIB'i'[I
�as xnxc�ov�rrr a�o.o�
ri�w c,�as Giur.i, s io.00
GAS UNiT HTR S10.00
FOOL HEATER 535.00
THIS IS AN APPLICATIdAi FOR A PERMIT NOT VALID UNTIL PROCESSED
I hereby apply for a build"mg permit and I aclmowledge that the information above is complebe and accurate; tt�t the work will be in
canformance with the ordi�nces and codes of the City of Frid�ey and with the M'inn�a Conshvction Codes; that I undetstand this is
not a permit but only an appiic�tion for a permit work is not to stazt without a permi� that the work will be in accordance witi� the
approved plan in the c�se of at work w' � review and appmval af plans.
SIGNATURE OF APPLIC� - � - — . _ _"�ME * ' , A `i� � � � 2
APPROVALINSPECfORSSFGNATURE .f �//LL(�/V 1 ne'r� Z/ 12
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
?63-572-3604 FAX: 763-502-4977