PRE 2010 DOCSVillage o3l" FrPldl y-9. Mhm.
fflj'�
N? 323 Office of INSPECTOR OF BUHI)INGS
Owner
Architect Fridley,
Bullder—�'i.
LOCATION OF BUILD1NG
No Street —Part
Lot Block Addition or Sub -Division
DESCRIPTION OF, BUILDING
Front–11'-- Depth 1�eight–K/-f Stories Manner of Construe
To be used To be completer,
/ 7�1
Cc
19 x ' /
Permit is hereby granted
the building described in the above statement. This permit is granted
upon. the express condition that the Gerson to whom it is granted, and his agents, employees and workmen, in all
the work done in, around and upon said building, or any part thereof,. shall confa nn in all respects to the ordi-
nances of Fridley, Minn., regarding the construction, alteration, maintenance, re] iair and moving of buildings
within the city limits, and this permit may be revoked at any time upon• violation i if any of the provisions of said
ordinances.
i2l, spector of Buildings.
AGREEMENT AND SWORN STATEMENT
In consideration of the issue and delivery to me by the Inspector f Buildings of Fridley Of
the above permit, I hereby agree to do the proposed work in accord nee with the description
above set forth and according to the provisions of the ordinances of n idley, and, being first duly
sworn, I hereby state and say that the facts stated by me and lcontain d in the above permit are
true as therein stated.
Subscribed and sworn to before me at Fridley, Minnesota,
J, �' ''
day A D. 19�--'/.
. J�
City of Fridley
Application for Plum ing and Gas Fitting Peennit
Dept. of Bldgs. Phone SII 4-7470
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures Location ° �" V `tl ` " ,/p
pp
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WATER HTR.
p
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a
(90
i
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GAS
ELEC.
Base
1st
2nd
-
3rd
4th
• Future Connection aiiakings
Connected with
I Sewer �
� New Fixture, Old Openings
Cesspool
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
Number Fixtures ......................
Future Fixture Opening ................
New Fixture Old Opening ..............
Catch Basin ............................
Water Heater (Up to 200,000 BTU) ......
New Ground Run Old Bldg. ............
NO. RATE TOTAL
— x $1.50 $
— x 1.20 $
x 1.00 $
— x 3.25 $
— x 2.00 $
— x 3.25 $ ��
GAS FITTING FEES: NO. RATE TOTAL
1st 3 Fixtures .......................... x $1.50 $
Additional Fixtures .................... x .50 $
Gas Range to 200,000 BTU .............. x 2.00 $
REPAIRS & ALTERATIONS—Refer to Code
Description .............................................
TOTAL FEE $
City of Fridley:
The undersigned hereby .makes application for a permit for the work here!
specified, agreeing to do an work in strict accordance with the City Ordinance
and ruling of the Department of Buildings, and hereby declares that all the fact
and representations stated in this application are true and correct.
�yFridley, Minns 19�
Owner Aa"'s 7L
Kind of Building
Used as
To be completed about
Estimated Cost, $
Old—New. Building Permit No Permit No. c::P, _C1 6
Signed -6�
By f CCS k�2d'�
Business Phone No -
ROUGH
FINAL
az 2M .
City of Fridley
Application for Plumbing and Cas Fitting Permit
Dept. of Bldgs. Phone 560-3450
DESCRIPTION OF WORK
Number, Kind and Location of Fixtures
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
Number Fixtures ......................
Future Fixture Opening ................
New Fixture Old Opening ..............
Catch Basin .... .......................
Water Heater (Up to 200,000 BTU) ......
New Ground Run Old Bldg . ............
NO. RATE TOTAL
— x $1.50 $
— x 1.20 $
— x 1.00 $
— x 3.25 $
— x $
— x 3.25 $
GAS FITTING FEES: NO. RATE TOTAL
1st 3 Fixtures .......................... x $1.50 $
Additional Fixtures x .50 $
Gas Range to 200,000 BTU .............. x 2.00 $
REPAIRS & ALTERATIONS—Refer to Code
Description ........................................
TOTAL FEE $
City of Fridley:
The undersigned hereby makes application for a permit for the work herei
specified, agreeing to do all work in strict accordance with the City Ordinance
and ruling of the Department of Buildings, and hereby declares that all the fact
and representations stated in this application are true and correct.
dley,
Kind of Building
Used as
To be completed "
Estimated Cost,
Old—New. Build
ROUGH
FINAL
Business Phone No
-j y u! Z
R
•
N
WATER HTR.
GAS
ELEC.
<i
O
v1
Base
1st
2nd
3rd
_
4th
• Future Connection Openings
Connected with
New Fixture, Old Openings
I Sewer El
Cesspool El
PARTIAL RATE SCHEDULE
PLUMBING FIXTURE RATES:
Number Fixtures ......................
Future Fixture Opening ................
New Fixture Old Opening ..............
Catch Basin .... .......................
Water Heater (Up to 200,000 BTU) ......
New Ground Run Old Bldg . ............
NO. RATE TOTAL
— x $1.50 $
— x 1.20 $
— x 1.00 $
— x 3.25 $
— x $
— x 3.25 $
GAS FITTING FEES: NO. RATE TOTAL
1st 3 Fixtures .......................... x $1.50 $
Additional Fixtures x .50 $
Gas Range to 200,000 BTU .............. x 2.00 $
REPAIRS & ALTERATIONS—Refer to Code
Description ........................................
TOTAL FEE $
City of Fridley:
The undersigned hereby makes application for a permit for the work herei
specified, agreeing to do all work in strict accordance with the City Ordinance
and ruling of the Department of Buildings, and hereby declares that all the fact
and representations stated in this application are true and correct.
dley,
Kind of Building
Used as
To be completed "
Estimated Cost,
Old—New. Build
ROUGH
FINAL
Business Phone No
0'Q
Application for Power Plants and Heating, Cooling, Ventilation, Refrigeration and
Air Conditioning Systems and Devices
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR:
RATE
TOTAL
Furnace Shell & Duct Work ..........................
8.00
$
Replacement of Furnace .............................
5.00
$
Repairs & Alterations—up to $500.00 ..................
5.00
$
Repairs & Alterations each add. $500.00 ...............
2.50
$
MECIL WARM AIA
Furnace Shell & Duct Work to 120,000 BTU ............ 8.00 $
each add. 60,000 BTU ....................... 2.00 $
Replacement of Furnace ............. 5.00 $ �®
Repairs & Alterations—up to $500.00 ................. 5.00 $
Repairs & Alterations each add. $500.00 .............. 2.50 $
STEAM or HOT WATER SYSTEM
Furnace Shell & Lines—to 400 sq. ft. EDR Steam ......
8.00
$
Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ...
8.00
$
Each add. 200 sq. ft. EDR Steam ......................
2.50
$
Each add. 320 sq. ft. EDR Hot Water ..................
2.50
$
OIL BURNER—to 3 gal. per hour ........................ 5.00 $
over 3 gal. per hour—See Fee Schedule
GAS BURNER (up to 400,000 BTU) ....................... 5.00 $ 6° 00
GAS FITTING FEES: NO RATE TOTAL
1st 3 Fixtures ...................... x $1.50 $ -q^6®
Additional Fixtures ................. x .50 $
Gas Range to 200,000 BTU ........... x 2.00 $
AIR CONDITIONING
FAN HEATING SYSTEM
VENTILATING SYSTEM
ALTERATIONS & REPAIRS
ROUGH
FINAL
See Fee Schedule
TOTAL FEE $ ®®
Dept. of Bldgs. Phone 560-3450
City of Fridley:
The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in strict accordance with the City Ordinances
and ruling of the Department of Buildings, and hereby declares that all the facts
and representations stated in this application are true and correct.
Fridley, Minn ./"�� � 19
Owner ;
Kind of
Used as
To be completed about
16- %9P4
Estimated Cost, $
Old New. Building Permit No. Permit No. ftf,Z(L_
DESCRIPTION OF WORK
HEATING or POWER P14ANTS_Steam, Hot Water, Warm Air—No
Trade Nam 24Size No. �f1 ez
Capacity 1®7- 600 Sq. Ft. E.D.R BTU H.P.
Total Connected LoaKind of Fuel A
BURNER — Trade Name Size No
Capacity Sq. Ft. E.D.R BTU H.P.
(REMARKS -OVER)
Signe
By
wO` , 42 Business Phone No
2D16a
SUBJECT
- _
City of Fridley
2099 3
AT THE TOP OF THE TWINS
I I IL ®I N G P E R M I j
BUILDING
Ir�
�,J
RECEIPT N
L. e COMMUNITY DEVELOPMENT DIV.
PROTECTIVE INSPECTION SEC.
/
rZ-q
�
CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
612-571-3450
910-F15
8/8/91
JOB ADDRESS 1626 Rice Creek Road NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
7
Aud. Sub.. #22 SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Fallinsten 1626 Rice Creek Road NE 540-4411
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Midwest Siding & Remodeling 50.3 Andall St, Lino Lakes, MN 55014 780-9799
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSE NO.
8 USE OF BUILDING
Residential
7 CLASS OF WORK
CR NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 161 x 12 i. Deck
9 CHANGE OF USE FROM TO
STIPULATIONS
See notations on plan, &out,
Ot .
A- R-
Before digging call for
all utility locations SEPARATE PERMITS REQUIRED -
454-0002 WIRING, HEATING, PLUMBING AND -SIGNS,
REQUIRED BY LAND
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
ZONING
SO. FT.
CU. FT.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN BO DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
NO. DWLG. UNITS
OFFSTREET PARKING
ANY TIME AFTER WORK IS COMMENCED.
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
1
STALLS GARAGES
VALUATION
SURTAX
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED®�
$1,4506 ®
$.73 1.619
WITH WHETHER PECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
PERMIT FEE
SAC CHARGE
DOES NOT P ESU TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
P ISI OF AN OTHER STATE OR LOCAL LAW REGULATING CON-
OF CONSTRUCTION.
$35.00
Fire SSC $1.4511
S RUCTIO R THE PERFORMANCE
PLAN CHECK FEE
TOTAL FEE
$37.18��"�'
IGNATURE FCONiRACT OR AUTHORIZED AGENT (DATE) V
HEN PROPERLY VAL TED YOUR PERMIT
r/IS
;yTHIS
SiGNATURE OF OWNERIIF OWNER BUILDER) IDATEI
BLDG INSP 1ATE
2D16a
ADDN [ ]
ALTER [ ]
bion Address: i
Legal Descr'iptian:
Owner Name & Address: rn r .v -
Cont aG'timy: irlicweb k -J-*^
LTVIM Atm,:
GUMM Ata:
AM:
on=:
Effective 1,/1/91
R-1 AND R-2
Building Permit Applicatim
PAS �4n Tel. # ®-- `✓�/ / t
Tel. # M —175�j
Attach to this application, a Oertificate of Survey of the
lot, with the proposed pian drawn an it to scale.
n:BQZIPI'= OF -nave ANT
length Width Height Sq. Ft.
Length Width Height Sq. Ft.
Length Width Width Hgt/Crn-d 30 q Sq. Ft. I q
I q"L )c `) e Ub C. 14s I. L-
Cbrner Int [ ] Inside Lot M Ft. Yd Setback ® Side Yard Setbacks g%
Type of Omstructicn: R Estimated Dost: $
Approx. Ompletion Date: Ir^9 ®� P
Prcposed Driveway Width If New Desired: Ft. $ $
Width + 6' See Back Page
DATE: i ( APPLICANT: S Tel. 9'755
Permit Fee $
Fire Surcharge
Mate Surcharge
SAC Charge $
Mriveway Escrow $
Park Fee $
Sewer Main Charge $
TOTAL $ '7
1.
Pee Sc herh:le an iaeverse Side
.001 x Permit Valuation (1/10th $)
$.50/$1,000 Valuation
$650 per SAC Unit
Alt. "A" or Alt. "B" Above
Fee Determined by MVi raw ng
NAY [ ] Not Necessary [ ]
. . *4V
I�
lo)e 7.,
3�d
CITY OF FRIDLEY INSPECTION DIV. Effective On March 1, 1996
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR PLUMBING AND GAS FITTING PERMIT
572-3604
MARK NUMBER
OF FIXTURES TO BE INSTALLED ON EACH FLOOR
JOB ADDRESS
UrInal-
Shower
Wash
Tray
Old Opening, New Fixture
Floor. Auto.Gas �imljw Water Heater
Drain Washer R an e
9 F 4 Gas Slec
Stor
Basement
Floor 1
$5.00
and rulings of the Building
uIlding Division, and hereby de .clares that all the facts
Blow Off Basin
$7.00
Floor 2
Catch Basin
$7.00
Rain Water Leader
Floor 3
Sump/Receiving Tank
$7.00
'1996
Floor 4
$10.00
Owner
Water Heater —Electric,
$7.00
PLUMBING FIXTURE RATES: NO.
RATE TOTAL
JOB ADDRESS
New Fixtures
$7.00 f-oo
The undersigned hereby makes application for a permIt.for the work herein
Old Opening, New Fixture
$4.00
specified agreeing to do all work In strict I accordance with the city codes
Beer Dispenser
$5.00
and rulings of the Building
uIlding Division, and hereby de .clares that all the facts
Blow Off Basin
$7.00
and representations stated In this application are true and correct.
Catch Basin
$7.00
Rain Water Leader
$7.00
Sump/Receiving Tank
$7.00
'1996
Water Treatln�g Appliance
$10.00
Owner
Water Heater —Electric,
$7.00
Water Heater — Gas**
$10.00
Building Used As
Gas Range"
$10.00
Gas Dryer**
$10.00
Estimated Cost PERMIT NO.
Back Flow Preve nter Required )Yes O No
Type
$15.00
PLUMBING COMPANYYn /��r�i ^
Reinspection Fee $42.00/Hr
S 10 N ED By TEL N0.
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
1.5% of Value of Fixture or Appliance
Approved By Rough—In Date Final Date
State Surcharge
$ .50
MINIMUM FEEL ANY PLUMBING/GAS PERMIT IS $20.00
TOTAL FEE
$
PLUS THE $.50 STATE SURCHARGE
**COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION
504(A) AND TABLE 6—A. MINIMUM SIZE 9 80 INCHES.
I Y
SUBJECT
P
City ®f Fridley
`
30982
AT THE TOP OF THE TWINS
BUILDING PERMIT
i o
r �
COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
%- CITY HALL FRIDLEY 55432
NUMBER
REV
DATE
PAGE OF
APPROVED BY
L J` 612-571-3450
910-F15
5/25100
JOB ADDRESS 1626 Rice Creek Road NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
1 7
Auditor's Sub. #22
SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP
PHONE
Lamoine Follingstad 1626 Rice Creek Road NE
571-9701
3 CONTRACTOR MAIL ADDRESS ZIP
PHONE LICENSE NO
Quarve Contracting 8427 Center Dr NE, Spring Lake Park, MN 55432 785-1472
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP
PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP
PHONE LICENSE NO
8 USE OF BUILDING
Residential
7 CLASS OF WORK
O NEW O ADDITION O ALTERATION Cj REPAIR
O MOVE O REMOVE
8 DESCRIBE WORK
Reroof House (15 Sq) Tear -off
9 CHANGEOFUSEFROM TO
STIPULATIONS
Underlayment must comply with the State Building Code.
Overpayment of $84.93 being held by cashier. Either apply to
next permit or come
into City Hall to receive.
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING.
TYPE OF CONST,
OCCUPANCY GROUP
OCCUPANCYLOAD
VENTILATING OR AIR CONDITIONING,
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SO. FT
CU FT_
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS. OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED.
NO. DWLG. UNITS
OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
1 ISTALLS
GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
VALUATION
SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
$1,311
$.66
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
PLAN CHECK FEE
T AL FEE
Licens C $5
, $57.92
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT iOATEi
HE PROP Y VAL
D THIS IS YOUR PERMIT
BLOG -NSP
` gArE
S-GNATU E OF OWNERaF OWNER BUILDERS iDATE,
I Y
NEW [ ] Effective 1/1/2000
ADDN [ ] CITY OF FRIDLEY (763) 572-3604 Bldg Insp
ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2
BUILDING PERMIT APPLICATION oj1 �6
Construction Address: X 'c6 e!5�-e-elz ,Al �J
Legal Description:
Owner Name && Address: Av wo,�te r��l��_c i�� Tel. # 7/-e�"%a /
Contractor: MNN��LICENSE # ®/
4.� /Cc Tel. #
v
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IMPROVEMENT
LIVING AREA: Length Width Height Sq. Ft
GARAGE AREA: Length Width Height Sq. Ft
DECK AREA: Length I Width Hgt/Ground Sq. Ft
OTHER:
Construction Type: Estimated ost:
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: APPLICANT: Tel. #
CITY USE ONLY - Call (763)2-3604 for Permit Fees if mailing In application
%6
Permit Fee ����✓�$ ® Fee Schedule on Reverse Side 5 (9 ici
Fire Surcharge/ 31 $ .001 of Permit Valuation (1/10th%) y 3
State Surcharge -GG$ $.50/$1,000 Valuation "(0(0
SAC Charge
0
$1100 per SAC Unit
License Surcharge $ 15. 6-Q $5.00 (State Licensed Residential Contractors) 5, O 0
Driveway Escrow $ Alt. "A" or Alt. "B" Above
Erosion Control $ $450.00 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ]
TOTAL $ 1 O l � Z
r(�
STIPULATIONS: �04
0,00
Building
WATER AND SEWER
Permit No.: 0 .-o
Inspections
PERMIT APPLICATION
Received By;;!��
763-572-3604
CITY OF FRIDLEY
Dat : A 20
763-502-4977 fax
EFFECTIVE 1/1/09
APPLICTATION DATE:'' ' DOl YOUR E-MAIL ADDRESS:
THIS APPLICANT ISII: 0 OWNER CONTRACTOR
_
JOB ADDRESS:
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY
NAME: LrreA4,
OWNER/
TENANT
ADDRESS: � lgZb �.:�.e, Cyee � Q�. iJ.� CITY �� � (2,
STATE Vt3 ZIP:S5-Zf 32—
PHONE: e3<
CONTRACTOR,
NAME: o -L. �n (_e,✓v :a C� o�,� wo
SUBMITA COPY OF
YOURSTATE
ADDRESS: I S `� (=1 ° au-" CITY
STATEZiP
WITH
PHONE CELL PHONE: -e3- Zgi&' Z -L,
APPLICATION
STATE LIC #QTY, lStJ 1 - M STATE BOND: EXP DATE:__ 1 3I - Z>1
PERMIT TYPE
Pair���f�
l f ❑ SEWER CONNECTION PERMIT $50
pit �(l ✓15 �I Vt�i ❑ WATER CONNECTION PERMIT $50
+VA 0, (OVA 10 �WATE EWE LINE REPAIR $40
LP
❑ ADD STATE SURCHARGE $.50
❑ SAC CHARGE @ $2000 =
0 ,
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER METER COST — SEE UTILITY BILLING
SPECIAL ASSESSMENTS — SEE FINANCE
WATER TAP — SEE ENGINEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT -NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and I acknowledge that the information
above is complete and
accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application fora permit and work is not to start without a permit.
SIGNATURE OF APPLICANT PRINT NAME:y �L+ e� DATE: 3 - (Q - p q
APPROVED BY:
DAT . -7'11-0 _
COPY GIVEN TO: D ILITY BILLING (only if new meter) PUBLIC WORKS
ftjNGINEERING
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
111
Building
i CHANICA�,
Permit No.: I f Imo`
Inspections
RESIDENTIAL APPLICATION
Received By:`
763-572-3604
CITY OF FRIDLEY
763-502-4977 FAX
EFFECTIVE 7-1-2010
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER )QCONTRACTOR
PROPERTY
NAME: L®, L $ %, ro 1 (a —, S s t A,%
C �L�
e �` TY FSTATE�ZIP6 �i33_
ADDRESS: i (-a CI
OWNER/
TENANT
PHONE: 143 - S-71 - q -7 o 1
CONTRACTOR
COMPANY NAME: 12, CL `� arj, tI
CONTACT PERSON: 0 go
SUBMIT A COPY OF
YOUR STATE
STATE LICENSE # EXP DATE
LICENSE WITH
ADDRESS: W t, H& NJ C CITY FK-I oSTATE"-J ZIP-,;,TV,
ib
APPLICATION
PHONE -7 63 -T ca 1 1. 1 FAX
PERNUT TYPE
'WSINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK:
❑ NEW -,T�-REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK J,-NB34A tc -1 r cb ()evi
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: (2,A-e-tic- MODEL: SIZEBTU c%Tyi
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE✓BTU
A/C $25.00 _FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 _FURNACE $35.00 _GAS UNIT HTR $10.00
CHRVINEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 _GAS PIPING $10.00 VENTILATOR $15.00
fi
3 �t
M .�hp Ei'+a a<" °,��:F �.�, k � E�h k k� � � � ��,t � l��j 'k $ J �3 iV ,� � y' 'rha"� �. $�. �� �,s "`a✓ �Lpv� � �/ .p( ��' '
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� _ h i t `H"' ��u.� ml�� � �� �•'�«� '�R �.. y. x E xo�c, s °g f _ t�w^'�k' b
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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 of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit 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 work which requires review and approval of plans.
SIGNATURE OF APPLICANT C PRINT NAME 0 t-% e dfs �ti,nDATE
APPROVAL INSPECTORS SIGNATURE DATE
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City ®f Fridley
]Building Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604 FAX: 763-502-4977