P - 45118Building
Inspections
763-572-3604
763-502-4977
DATE
SITE �DRESS
TfffS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERNIIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTI4E 2-19-09
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?,DDRESS:
YOCIR E-MAIL
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COAIP.�TY N.�1I�fE: ...,.a��..a�.. �..�.� .� .... ... ..........._... .
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CONTACT PERSON:
STATE LICENSE it Fa��� DATE
:aDDRES S:
PHONE
FAI�IIL1" ❑ Tli'O F.�IILT
❑ NE�I' �REPL.ACEr4ENT
DETAILED DESCRIPTTON OF WORK
CITY
FAX
❑ TO�SNHOUSE
❑ aI.7�R.�.TION'REMODEL
Permit No.
Recei�-ed B�-:
D���`
ST
T'E ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FTXTURES: (INDICATE TOTAL NUMBII2 OF EACH BELO�
Equipment Installed MFG_ MODEL: SIZFJBTU
MFG: � MODEL: � / � SIZFJBTU _��'/ V �
—[ —
MFG: MODEL: SIZFJBTU
A/C 525.00 _FIREPLACE (GAS) 515.00 _GAS RANGE/OVEN 510.00
_AIR TO AIIi EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL 510.00
BOII,ER S35_00 �FURNACE $35.00 GAS iJN1T H'IR $10.00
_CI�EY LINER $10.00 GAS DRYER $10. W POOL HEATER 535.00
DUCT WORK $LQ.OQ GAS PIPING $10.00 VEN1`II.ATOR 515.00
THIS IS AN APPLICATION FOR A PEI2MIT-NOT VALID IINTTI, PROCESSED
I hereb<< applv° for a building perniit and o��%ledge that the information above is coniplete and accurate; that the ��ork t��ill be in
conformance �vith the ordinances and es e Cily of Fridley and �aith the Minnesota Construction Codes; that I understand this is
not a pemiit but o ation f a pe ii and work is not to start with t a perniit; tt�at the �vo r t�-ill be in acco ance �vith the
approved plan in e c a work �c req es revie� and approval of p s. �
SIGN.�TC�RE UF _ N.�hfE ( � /y� ,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977