P - 39641� �-oi-�at
Building 1���;'��.N���� perr��it rro.:
I11SpeCtiolls ����j��T'�'�,c��, �g,���,���'�'��� Received By:
76�-�72-3604 ��r*�� �� ������ Date Rec'd: � l
763-502-4977 FAX EFFECTIVE7-1-2010
DATE Q-- �J -�� YOUR E-MAIL ADDRESS
SITE ADDRESS % Sv �/ / �-G ( i � q'j � '1 !� �° N � ��K= � � ('-r �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY NAME: G� ��` �jA C k... �"� 4^
OWNERJ ADDRESS: I SJ v � �'� f( I�.a^ t� i�� !�i 'CITY Fr't-t �?1� : STATE �''��ZTP �� ����
TENANT rHOtvE: �(,:3 ° S t f-� � 5 v�7 ��
CONTRACTOR COMPANY NAME: )L Vi ✓ �[ � �ti �` �' �� r �t
SUBMIT A COPY OF CONTACT PERSON: C-� 4' � ��
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: �� S� G'� ���-. '� � �� CITY �IQ� � � n STATEn �'' ZIP� S I�`�
tiPPLICATION pHONE �� �'� � 5'E � � '� 7 FAX ��
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PERMTT TYPE SINGLE FAMILY O TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �PLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �%- f1 s�r (1 t2 • � 1 �-� �`�.i �-.h '�u�.v� � � � `� �4� r� �d✓'� c � � �u��
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTCTRES: (INDIGATE TOTAL NUMBER �F EACH BELOVS�
PROVIDE HEAT LOSS CALC'S PER MANU J 2AI,� 006 ASHRAE HANDBOOK
Equipment Installed MFG: �Lv �J fJ MODEL: ;2G��7 U L �e"'�+0 �T SIZEBTU � �_ '� � �
R G MFG: ,;� �r v'� MODEL: U�°''� `� 0 3 �-+ F` z" SIZEBTU c� ��a t U�'1
j MFG: MODEL: SIZEBN
` A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10,00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35,OQ NEW GAS GRILL $10.�0
_BOILER $35.00 �FURNACE $35.00 GAS tJNIT HTR $10.00
CHIMNEY LINER $]0.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $] 0.00 GA5 PIPING $] 0.00 VENTILATOR $15:00
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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 for a permit and wark is not to start without a permit; that the worlc will be in accordance with the
approved plan in the case of all work which requ' •es review and approval of plans.
SIGNATURE OF APPLICANT � I t!�. � T PRINT NAME \- � f� � �� ^� % D T���S "� P
APPROVAL INSPECTORS SIGNATURE DATE �
' PLEASE NOTE:. SEPARA.'TE p,E `." RE R�QTJIR�I7:F�R BUIL'L?iNG, �i.+EC1'RIG l. AND :�HANICAT.� 1��RK.
Citv of �ridlev
Building Inspections Depaa-tment
6431 University Avenue NE, Fridley, MN 5�432
763-572-3604 FAX: 763-�02-4977
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