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T�nspections
763-572-360a
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DATL- 1 1 V \" �
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SITE ADDRESS �
THiS APPLICANT 15:
OWNER�
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�ON'�'RA�'1'OR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATI ON
I'ERMIT TYPE
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YOUR E-MAIL ADDRGSS
❑ OWNEP. �ONTP�ACTOP.
Permit No.:�)
Received By:
Ja . � ,cf�
NAME: p,�� 1� }' 1� G re �.l � be,
ADDRESS: I^� S T1� � r i d l c,u STATE ZII�S c/3 �
PHONE: ' oc ! � So� I
COMPANY NAME: �`��r �e��� �'��� B�i�''��.. � F«�pI�C�
CONTACTPERSON: ��G�Q ��l4�'s ,,�,3k. IOE.L., ��site 39
STATG LICLNSG iS Fi"IfE�e?i�'_ �"�1� �d$`�
ADDRI:SS: IT� STATE • ZIP
- a 4
PHONE PAX
❑ SINGL� FAMILY ❑ TWO FAMILY
❑ NEW �BEPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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rEES ARE BASED ON �10.00 PER FIXTURE, EXCEPT WHERE NOTED. FA"IT7RES: (INDICATE TOTAL NUNIBER OF EACH BELOW) �' '
PROVIDE HEAT LOSS CALC'S PER MANi1 J 2�HILA� HANDBOOK y},/�p[�
Equipment Installed MFG: MODEL�__� ! _ _ _ � / / � ' i`.- .7eIZE/BTU �oi O� �
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
_A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVIN$]0.00
_AIR TO AIR EXCHANGEER $15 , _ , .. , _FIREPLACE (WOOD) $35,00 . _.._ . NEW GQ,S GRILL $lOA�R. �r�r rr. m^.r. A
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_BOILER $35.00 ' : yJ�rFURNACE $35.00 - _GAS UNIT HTR $] 0.00 v_ y ; ,_ ,
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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE . e% � �
SITE AD RESS S_%!/
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING Permit No `' ' - �
RESIDENTIAL APPLICATION Received By:V I �<
CITY OF FRIDLEY vat(����'dE � � �
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YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
PHONE: /r7 Lr�— �"7 / �
CONTRACTOR NAME: �/>[i[/,�� �,���s�i-tiG
SUBMIT A COPY OF Do,7 ,/,/
YOUR STATE LICENSE STATE LICENSE # ��5, �q`•'
AND CERTIFICATE OF ADDRESS:
INSiJRANCE PHONE �J�' � r
PROPERTY TYPE �CSINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION ❑ UA�U
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
DESCRIBE WORK BEING DONE:
RTZF nF iMPR(1VRMFNT
LEAD CERT NUMBER
CITY�
FAX %%] - (U �
SIZE
STORIES
�.WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ ADDITION
❑ REMODELING
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'�%�"��EXP: (p/i!
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