P - 35207Building
Inspections
763 -5 72-3 604
763-�02-4977 FAX
DATE_ �����I
SITE ADDRESS __--���(
THIS APPLICANT IS:
RoPERT
OWNER!
TEN AIYT
MECHANICAL
RESIDENTIAL APPLICATI�N
CITY OF FRIDLEY
EFt-ECT[VE 1-I-201 E
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ADDRESS:c.��„���(/J�iT��.___�_� C;17�Y
r�xorre ��<a 3—.�`i� —� d? � 7
Permit Na.: -u��-'U
Received By; ,/ t+ �r�1''
Date�`D: .! I 1 I_ 2 0 11
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l:U1V 1 KAC 1�UK i COMP.4NYNAME: L2f5Q11 PIUIY1�If1C�, InC,
SU13M1"I' A COPY OF ; CONTACT PERSON: IN@�iC�Y NG�50(1
YOUR S`I'AT[i STATE LICE2JSE q 58757 (3341) F� nnTE
►.icr;NSH w�rr�� �DRESS: 3095 162nd Lane NW C[TY Andove� srATEMN �P 55304
APPl.1CA"l'ION ; --._._..._. . _n.__ �..._.e
�HOrv� 763-427-7680 w�a,x 763�27-9448
PERN1lT TYP� ,�SINGLE FAMILY ❑ i�1�"C} FA'1iILY
TYPE OF WORK: O tiF�4' ❑ RF.PI.ACF.MF.NT
bcrA«�ca �cseRi�r►o�v o� wo�x
❑ T(7�T(HC3USE
A I_TFRATION/RF.. ViODF.[.
FEE� ARE B�,SED ON $10.U0 PER FLkTI RE, EXCEPi 1� HERE ;VC)TEU. F1XTl,'RES: (I!VD[fATE "rt7TAL NI!II[BER (}F EACH BELOW}
PROV[DE HE 1T L0.S5 CAZC'S PER'1IA:tit«� J 240G ,aSHIt�1E HA(VDBOOk.
Equipmcnt {nstallcd ���,� !4fF(i: �%� ' '�tODEL: /�%0���%�� SIZE�BTU �Q, � , _
�G 14iFC; �UiLf.li ;4lODEL: L%L� I�/{'!U�-�(�� � SIZE;BTU oZ %d N
MF{ i• MODEL:
� /UC $25.00 � _FIRFPLACE (GA5) $15.00
AIR TO 11iR EXCHANGEER $15 FIREPLACE (WOOD) 535.00
B[)tLER S.i�.Gt7 �FURNACE $35.00
�CH[MIvEY L1VER �10.�0 G.45 DRYER $]0.00
Dt:CT 1VC?RK 510,(70 G.4S PIPIN(i $10A0
SIZElBTU
_GAS RANGE/OVEN S 10:00
i�EW GAS GRILL SI O.QO
CiAS iTV1T HTR $]0.00
�POOL HEATER $35.00
VENTILATOR TI5.00
iHIS IS f1N APPLICAT'ION FOR A PER;4iIT-Vf?7 VALID i.1?ITIL PRi]CESSELI
I hereby apply far a buildin� pennit and I acknati�fedge that thz ir,foimation above is camplete and accurate; ti�at the work will be in
conformance �vith the vrciinances and ades of the City af Fridley and ��.ith the Mirnesota Construction Codes; that I understand this is
nat u pettnit but anly an appli tion fo , err;�it nd �vork is nat to start w•ithout a pennit; that the wark .�ii} be in accordance with the
approved plan in the case of work whic q res review and approval of pl�ns.
SICeN.1Tl.'Rf:Ci}qpPl.li:',4N �'l��— PRiNT�.A'VIE ��i��l�,S��`1� / DATF.. � � l�
APPROVAL INSPE(:TOR.1
DA
City of Fridley
)Building lnspections Department
31 �niversity t'lvenue NE, Fridiey, MN 55432
7fi3-�72-3604 FAX: 763-5�2-4977