P - 35837Bulldirig �����ly.�T��.�.�, Permit No.: ` ;
I1lspections ����j�i �'�'�,�,�, �g,�►�,���;�'�'���T Received By:
763-572 36U4 ���'� �� FF.����+ � � �'�: � � � ��
76�-J�2-4977 F� EFFECTIVE7-1-2010
DATE �" N T i! YOUR E-MAIL ADDRESS
siTEaDD�ss `�3b0 �t�r-r�Ph 1 rG+C tJ� �r�iQ���
THIS APPLICANT IS: ❑ OWNER �1CONTRACTOR
PROPERTY NAME: l ✓►O�C�A�• �t � .r� ^�.,�
OWNER/ . ADDRESS: % 3�m � {.� na �L�. C. � � CITY ( IQ� +O � �i STATEH� ZIP �S� `F �i-
TENANT PHONE: ? b3 ^ d� z-- � ri r�
CONTRACTOR COMPANY NAME: d v � � �� b-I �-�
SUBMIT A COPY OF CONTACT PERSON: Cti ✓�3 �AA
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: e190 �..iw Sb• a'E CITY �K.t W�S� STATEM'J ZIP����-
APPLICATION pHONE '1 63 7S'{� p7l Ct � FAX
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �rIS� e� i ✓1 Lr0 IO-c.►� �� �- 7Q t�-- C6ti� t F��.�.�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOR�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK. a�'U n
Equipment Installed MFG: �A �� MODEL:�r� � 3 A1 i� �`�' SIZE/BTU
_ MFG: MODEL: SIZEBTU
'MFG: MODEL: SIZEBTU
A/C$25.00 _FIItEPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $I S _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.U0 _FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 � _GAS DRYER $10.00 _POOL HFATER $35.00
DUCT WORK $] 0.00 GAS PIPING $10.00 VENTILATOR $I5.00
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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 far 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 work which requires review and approval of plans.
SIGNATURE OF APPLICANT �� n-� ��Ib PRINT NAME l��'1 r:1 / V�,dYJ DATE�'" �� t r
APPROVAL INSPECTORS SIGNATURE DATE
". ~.."PL���:N(7'I'� ;'��P�1R��'E.P,.,�T��'I�S:�1R'E:R,��i:TIR��'-F.,{��:HUI1;Di1�iC;���'C'I'R.��AI:: ANI�!wi��`HANICATW';t�t��:;:. :°
t;ity of 1+'ridiey
Building Inspections Department
6431 University Avenue NE, Fridley, 1ViN 55432
763-572-3604 FAX: 763-502-4977