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�ns�e�tiar�s
763-� 72-�604
7b3-� 02-a97 i ��
DATE 1 � - i- I �
SITE ADDRESS
THIS APPLIC.�NT IS:
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SUBMIT A COPY �P
YOURSTATE
LICEI�ISB WITH
APPLICATION
PERMIT Ti'PE
'PYPE OF W�RK:
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YOUR E-MAIL ADDRESS
❑ OWN�R '�`CONTRACTOR
1 Gllilil 1yU.: �JV (�(��j�,y�J'j�
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Received By: '
Dat���['�i: � �/ 4 2�
NAME: _ �{�+ t h Z t�. 4- W f i,�..
r'aDDRESS: `J ��� �.,�. 3`�c�:�: � z L lG i")�- r��� CITY f-'�V i �OC=..a STATEi^iJ ZIP >�J �3,Z
PHONE: 7 6 3� S I J- � �� "�` `� �
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COMPANY NAME: Yf�.� �u . u � F J�'� c4 � t# r l
CONTACT PERSON: C�✓�� : ��.� n'Y r°
STATE LICEI3SE � EXP DATB
ADDRESS: x� y' �5 iS"� N. R-. �i: �'`'� CITY ��"�t r.?f � STA.TE f`t�'`ZIP.�1' Y3Z
PHONE �? � 3 `7S �/ � l �i �1 FAX
y�INGLE FAMILY L� TWO FA.MILY
❑ NEW �REPLACEMEI3T
CJ TOWNHOI]SE
❑ ALTERATION/REMODEL
DETAILED DESCRiP'TION OF WORK �i'i �� �, ► i �''�,z.� � �- �u v°rc:� +� (=�.. � s,�1 �..: � 1('i � r,� c.o �rc� � � �o-�,"••
REES ARE BASED ON $10A0 PER FIXTURE, EXCEPT WHERE NOTED. FiXTURES: (INDTCATE TOTAL NiJMBER OF EACH BELOVVj
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASIiRA.E HANDBOOK
Equipment instalied MFG: �y v.., t� MOAEL:� (� �=� �g o C-�� �!: s SIZEJ�Ti� � � ���
MFG: v�' v v� MODEL: U� F��- Oy y Jr '�-- S�'U � T�"�
MFG: MODEL: SIZE/BTU
i A/C $25,00 FIREPLACE {GAS) $15A0 �GAS RA,NGEIOVEN �10.00
AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 I�TEW GAS GRILL $10.00
BOILER �35.00 �FURNACE $35.00 GAS LJNIT HTR $70.00
_CHIMIJEY LTNER$10.00 ^GAS DRYER $10A0 �POOL HEATER $35.00
__ _DUCT WORK $10.00 ,GAS PIPING $I OAO ,VENTILATOR $15.00
TH1S ?S AN APPLICATION FOR A P�RMIT-NOT VALID UNTIL PROCESSED
� hereby apply �or a buiIding �ermit and 3 acicnowledg� ttlat the information above is complete and accurate; that the worlc will be in
woniormance with the ordinances and codes ef the City oi Fridle�� and with ±he Minnesota Constructian Codes; tizat I understand this is
not a per-nit �ut only an appiicwtion iar a vermit and �voric is ❑ot to start vviclzout a permit; that the wo��zc �vill be in �ccordanc° ,��ith the
aoproved ;�lan in tlle ��ase oi all �WOrl: �Niiic:l re�uire� revie�,v anci approvai �i plans.
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