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II�Spe�t10Ii5 �����i j�'�`�.f�� 1�.�����,.c� "��� Received Ly f-
�6�-572-�604 �;��'� ��+ ������ Dat��d : ,
76�-502-497i rA1� EFFECTIVE?-1 �010
DATE 1/- �y . t U YOUR E-MAIL ADDRESS
SITE ADDRE55 �.7 � Iid ��'4 LF�.�. tl�, �
THIS APPLICANT IS:
PROP�RT'�'
O WNE�2/
TENAN'T
CON'i'ItAC'TOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
NAME: K L t�`l,. J�. �,a a�Cv-,� ��-
aDDx�ss: 8,�'/ H a o.�L 4,1�.. 1� w CITY �r�. r,�( �� STATE 1`l � ZIP ,,�J V3.L.
PHONE: 7 �:� - .��7 � - 1'] �'°J
C�MPANY NAME: %L i V i s
CONTACT PERSON: Gn r t
STATE LICENSE # EXP DATE
ADDRESS: �a-�0���-- S�• tJE CITY �IQ.! (� STATEri'`' ZIP S��
PHONE � 6� ?� �� 4 R FAX
�3INGLE FAMILY � TWO FAMILY
i7 NEW �( REPLACEMENT
❑ TOWNHOUSE
❑ ALTERATIONIREMODEL
DETAILED DES CRIPTION OF WORK �n .3� � I �,n (�� ,.-t �.., � j- k o�, r► A��-
r
FEES ARE BASED ON 510.00 PER F'IXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDiCATE TOTAL NUMBER OF EACH BELOW)
PROYIDE HEAT' LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: 12v v A MODEL: �:G�2� d 6 E r( Ak'S SIZFJBTU ���_
MFG:
MODEL:
51ZE/BTU
MFG: MODEL: StZEBTU
A/C $25.00 _FIREPLACE (GAS) $15.00 _,GAS RANG£/OVEN 510.00
AIlZ TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 �FIIRNACE $35.00 _GAS CJNIT HTR $10.00
CHIIvII�EY LINER$10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
_DUCT WORK $10.00 _GAS PIPTNG $10.00 _VENTII..ATOR $15.00
THIS IS AN APPLICATION POR A P�RMIT-NOT VALID UNTIL PROC�SSED
: hereby apply �or a building permit and I ac!cnowledge that the information above is complete and accurate; that the worlc will be in
vonformance with the ordinances and codes of the City oi Fridley and with the Nlinnesota Construction Codes; that I understand this is
�ot a permit out only an application ior a permit and ��vork is not to start ,�vithout a permit; that the wor3c �•Nill be :n accordance with the
aporovea plan in the case of all �.vqric �,�hic:i requires revie�,�v and approvai oi nians.
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