P - 44964Building
Inspections
763-572-3604
763-502-4977
DA� LL I
SI1'E ADDRESS
THIS APPLIC aNT IS:
PROPERTY
OR'NER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 2-19-09
!-l�J �
�}�
❑ O��NER
N.�:
ADDRESS: ' �
PHONE: r% /'
�i'OUR E-MAIL ADDRESS
�,�.�,
con�.�n rr.�¢. �.a���a�.. � ��a.,,.y M ... ......_........ .
CONT.�CT PERSON: y
STATE LICENSE # F � 7�R�d_7� DATE
ADDRESS:
PHONE
❑ NE�L'
CITY
FAX
F;ahiILY ❑ 'f�;�0 F.Ah-III.1 ❑ TOWNHOUSE
�ACEI�•�NT ❑ ALTER.�.TION/REMODEL
DETAILED DESCRIPTION OF WORK
Permit No.
Recei�-ed By:
Da�e�dt w `� ��` �
.TE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: {INDICATE TOTAL NUMBFR OF EACH BELO�
Equipment Installed MFG: MODEL: SIZFJBTU O
MFG: MODEL: � ` v SIZF/BTU
�/ MFG: � MODEL� ��� SiZFJBTU � r��
/\A/C 525.00 FIREPLACE (GAS) 515.00 GAS RANGE/OVEN 510.00
_AII2 TO AIIt EXCHANGEER $15 FIREPLACE (WOOD) 535.00 NEW GAS GRILL 510.00
BOII.ER 535.00 �FURNACE 535.00 GAS iJDIIT HTR SI0.00
Cf1I1VIlVEY LINER 510.00 GAS DRYER $10.00 POOL HEATER �i5.00
DUCT WORK 510.00 GAS PIPING $10.00 VENTII,ATOR 515.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID IJNTII, PROCESSED
I hereb5� appl� for a btulding pemiit and I acknoi�%ledge that the information abot e is complete and acctu-ate; that the «°ork c��ill be in
conformance °�th the ordinances an of the Citti of Fridle�� and with the Minnesota Construction Codes; that I understand this is
not a pe but } pplicatio or a miit and work is not to start «�ith t a permit; that the wo 4vil1 be in acco ance �vith the
approv plan � I e �of all w ch equires review and approval of p a�is. , ,� � � � �
SIGNAT[,Rt� OF
N_�4E
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977