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From: 6127246856 Page: 2!2 Date: 3l18/2011 1:08:13 PM -°°'�s+^�� j_�`� �(�
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YOUR E-MAIL ADI?RE3S /�"1l�"���'
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TENAN'Y' PHONFs� i�'a, ��_L_��� _ _ _
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CONTRAC�UR CpMPANYNAME: ' J ` r� /� �+�r"'!a�-'
SUBMiT A �OPY O� �Ni'ACT PE�tSON: /��l�c= �—"' � ;�I °// _
YOUR STATE STATE LfCENSE f�_.� Bxp na�rE
LICENSE WITH ADARESS;���,`� ,��t��IlNG> CiTY STAT�3,�Jj0�%lP S'S'�!�
AIyPLICATION PHONE �°%�'•%��'S6�/ _ , r•nx y. i� "��
pERMiT TX�'E
TYPE OF W4RK:
{�SINGLErAM1LY G1'fW�FAMILY
O NEW �KfiPLACEMEN'I'
o Towr�aous�
❑ AL'i'BRAT10Nl[LE1�i0D�L
DETAiLEADESC�IPTIONOFWO�K � ��/ �f '�'�'Y�'�m �f'�"�� �'�B�
.,..�.
Tf �S ARE SASED ON 5�10.09 PER FIXTIJRF„ EXCE.PT W�ER�: N07'��1. F(XTU�tFC�: (AVnICr#'��: TOTAL NUMBL�R OF EACk: BELOW}
PROVi,bE HEA'C LUS.4 CALC'� PER MANLiAL .12406 ASHrtAE HAN6BOOK. gIZ�/STU,^,�_.—
13quipmcnt Installcd MFG: _ _ , MODEL. �„,��
MF'G: �..,,��� MOriEi.: -�� S17•EII3TU .�" a'�
MOf1fiL: 81ZE/DTU
MFG� �._. GAS RANGE/OVSr1 10.40
NC �25.00 „r,_PiR�PI.ftCE (C*AS) $ i 5,00 ���y �pS GRI►.L $l0.00
^A1R TO AIR EXCHANGE�R Sl S 1�1RT?PLACE (WOOD) $35.00 (;AS LMl'C HTR $10,(10
,�X,BOf[.ER 535,00 �FU�,NACE $35A� ppp�, HFATER i34.00
CHTMN131' L1NE� �10.00 GAS L�RXI?R �10.00 V�NTILATUR 515,00
�DUCT WbRK S10A0 ariS P1FiNQ �xQ,00
.. . .__._..,,,. W,.. �sa���« .0
'fl-11ti iS �N APPLICATTON FUR A P�RMI'T'-NOT VALiD UNTIL f ROCL'SSED
I l�et'eb y a p}�ly for a building peiznii ,G�id I. acknowledge that tl,e infonnacion above is com.plete �.nd accu�ate; that thc wrn-k will be in
conformance with the orc3inances anc l co des o f t he Ci ty o f F ri d l c y a n d w i t h t l� e M i n n e s o t a C o n s t r u c C i o n C o d e s; dyat .I understAnd 1h?s is
not a pertnit but onfy an appLicax�on 1'��r s� per. it and work is not to gcaa�t without A permit; that the work w'rll be in accordance with the
approved plan in the cx.gc of �ll worl ich e>>res review flnd approvA.l afpians.
LY//u� Oli� � i DR iNT Tl AMF. f!//CJ�7l`•r� '��..�L���� � I�I/
SiCiNlATURC aF APPLICA]V'l�
AriAROVAI� rNSr��rpus s
c�� o� a�r�a��y
Z3ualclyng �nspections De�artx�aent
c;�E:31 Ux�i.versity A.venue NE, Fridley, MN SS432
7�3-572��6a4 �f1X: �63-542-4977
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