P - 48132Building
Inspections
763-572-3604
763-502-4977 FAX
DATL �� — /� —
SITC ADDRESS ���
THIS APPLICANT IS:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY -
EFFECTIVE 2-19-09
❑ OWNER
YOUR �,-MAIL ADDRESS
Permit No.:��U ���1�� 1
Received By:����
, �� �
PROPERTY NAME: f� OXFINNt / /']ULN7
OWNER/ ADDRESS: S�:f�'1� CITY STATE ZIP
TENANT pHONE�%(o3 S�' Ce C703 �
CONTRACTOR COMPANY NAME __ __ ___.
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SU13M1"I A COPY 01= «�Nl'ACT PERSON __
n� — -..._ _
YOUR STATE STATE LICENSE# �u�c ��g 9�01
LICENSE WITH ���
ADDRESS: ��tz� w�SLQti97C�TY STATE_ZIP
APPLICATLON pHONE F FAX
PERMIT TYPE �SINGLE FAMILY O TWO FAMILY
TYPE OF WORK: � NEW �REPLACEMENT
I)L;"I AILED DESCRIPTION OF WORI<
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
f� Gl:ti :U21? 13ASCD ON $10.00 PI:R �IXTURE, EXC�ERE NOTED. FIXTURES: (IND[CA�T O AL NUMBER OF EACH E¢ kO)
Gyuipment Installed MFG: MODE ' 1 �� � SIZE/BTU,�%U _
AiC $2� 011
--
_,4II: "fO:�IR I.'XCHANGGCiR �I i
R(�II.I;R x35 00
CIIIM�'LY I_INIiR $10110
DUCI �1'Ukl<;;10.00
M FG:
MODEL:
M FG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35 00
gFURNACE $35.00
GAS DRYER $1000
GAS PIPING $I0.00
Number of fixtures @ $10.00 x $1A.00 ° $
Number of fixtures @ $15.00 x $15.00 = $ '
Number of fixtures (a� $25.00 r x $25.00 = $ : �i:
. : 3� y iy', .
Number of fixtures @ $35.00 � x $35.00 = $�.'� �' `
�.���� � 4.�
State Surcharge = $
_� I � I�.�-
S[ZE/BTU
S(ZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HF.ATER $35 00
VENT tL.ATOR 51 � 00
aY
i!P y '
(MINIMUM FEE $3'�9j'Tota1= $ '' yU : �:;.
THIS IS AN APPLICATION FOR A PERM[T-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and [ 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 for a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in�ttt-sa of all work which requires review and approval of plans.
SIGNATUREOFAPPLICANT ���., PRINTNAME 1M L.���F� DATE � 7"
PLEASE NOTE:
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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