P - 35265Building
Inspections
763-572-3604
763-502-4977
DATE__ _�_�_
SITE ADDRESS `
THIS aPPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
MECHANICAL
RESIDENTIAL APPLICATION
F� CITY Or FRIDLEY
, EFFECTT�-'E 2-19-09
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERM[T TYPE
TYPE OF WORK:
: YOUR E-MAII,
Penrut No.- � �
Receired B�> : �V� (,' ��
l�tp��ec�
pftl,
❑ O\1NER CONTR�CTO
N.�1E: C�( 'e
�DU�ss: r c � sT�g
PHONE: �n /� a.� �-�'�/ � O�% g 10
�
�or.�:�> N.;�¢_ Standard Heanng ir on ornng
CONT,�.CT PERSON: y �
STATE LICENSE 1# R 17 R7d_7�' DATE
ADDRESS: CITY STA'TE ZIP
PHONE __ FAX
FA14IIL7' ❑ T�i'O F.AI��III.1'
❑ NE��' �O1�EPLACEA•tENT
DETAILED DESCRIPTION OF WORK
O TOIi�T+IEiOUSE
TERATION�REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACIi BELOVi�
Equipment Installed MFG: MODEL: SIZF/BTU
MFG: MODEI.: �Y SIZFJB O � �
�/ MFG: �_ MODEL: SIZFJBTU �i—' ( �1
%� A/C 525.00 PLACE (GAS) 515.00 GAS RANGF/OVEN 510.00
_AIIt TO AIIt EXCHANGEER $15 PLACE {WOOD) $35.00 NEW GAS GRII.L 510.00
BOILER 535.00 .�FURNACE $35.00 GAS UNTT HTR 510.00
CHI1bII�EY LINER S 10.00 _GAS DRYER $10.00 1�OOL HEAIZ�R 535.00
DUCT WORK 510.00 GAS PIPING $10.00 VENI�ATOR 515.00
TEIIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNITL PROCESSED
I hereby apply for a building perniit and I acicnon=ledge that the information abov°e is complete and accurate: that the ��-ork t��ill be in
conformance �vith the ordinances and codes o itv of Fridley and ���ith the Minnesota Construction Codes; that I understand this is
not a perniit but }' an cation for t vvork is not to start �v°ith t a pernlit; that the wo t�rill be in acco ance �vith the
approved plan � the cas of I�ork c equues eview and approvai of p a�s. , ,� � � / ,
sicNaz-�,�
N_�fE
v City of Fridley
Building Inspectioas Department
6431 University Avenue NE, Fridley, MN 55432
���� -- ,�763-572-3604 FAX: 763-502-4977
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