P - 48005�uilding
Inspections
763-�72-3604
763-502-4977 FAX
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CI'I'Y O� Fi���,EY
EFFECTIVE 7-1-2010
Permit No.:
DATE �✓' �3 '( j YOUR E-MAIL ADDRES3
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THIS APPLICANT IS: ❑ OWNER �ICONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMTT TYPE
TYPE OF WORK:
NAME: M i IC_:. L t)..
eived By
� ���
ADDRESS: 1;;3 l� % (�f A,� l�� � r� ��o.� ^J� yJC CITY�rG //11t�. STATE ,'y P.iZIP � � Y,i�,
PHONE:
COMPANY NA[vIE: � l v t�
CONTACT PERSON: (` h �
t-� t F �--
STATE LICENSE # EXP DATE
ADDRESS: �c�` �� M a. t�n �v� N'.: CITY ��i:- t f 1�� STATEJ�1 J� ZIP $ s�f3�
PHONE � �' 3" `7 � �( �° a � 4 �1 FAX -�
� SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
❑ NEW �REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK ..1--✓; ��-� (( rL 2� i�i,i r► t r1 ��u. n� s� e_i, '� A/�C.' (_ G:-Z :y( �� � pv� r,r
FEES ARE BASED ON 510.00 PER FIXTURE; EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: ��.� Y*� ';_. MODEL: ��� � t`� � Cs'� (1 �'' D SIZEBTU (a �� � G c
MFG: � 4 Y P? � MODEL: i� A 1.3 N� �,�L{ f7K(y SIZE/BTU c� �( U''}
M�G� MODEL:
�A/C $25.00 FIItEPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
_BOILER $35.00 �FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
DUCT WORK $10.00 GAS PIPING $10.00
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS iJNIT HTR $10.00
_POOL HEATER $35.00
VENTILATOR $15.00
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 o�'the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicatio far a p�i-nhit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all wor�whict�`requires review and approval of plans.
SIGNATURE OF APPLICANT C �^ /1 �.
AL INSPECTORS SIGNA'
C� f �s
DATE
City of Fridley
Y C=+`. ���d'i° BATE � ' I -
Building Inspections Department
6431 University Avenue NE, Fridley, MN 5�432
763-572-3604 FAX: 763-502-4977