P - 60358Building MECHANICAL Permit No.
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY �� ��f� '� � ��
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE � � � ( /` YOUR E-MAIL ADDRESS
SITE ADDRESS ys� % � �L � � • /�I• G .
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY NAMg: Sof�� f�or�p,Son
OWNER/ pDDRESS: 'yS.'2 % O� �s S� /✓, E CITY F! u� �C'� STATE�iIP,�[��
TENANT pHONE: 7�? ,3 - S �� - 7 7 0�t
CONTRACTOR COMPANYNAME: a .-rnr_�=Tl��n�,TH 8t HOME
SUBMIT A COPY OF CONTACT PERSON: ��TgC0512060
YouR sTATE sTaTE LicENSE # ExP vaTE �00 FAIRVIEW AVENUE N
LICENSE WITH �D�ss: cz� ROSEVILLE, MN S�l� Z�
APPLICATION pHONE FAX 651.6 •
PERMIT TYPE J�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK• �NEW ❑ REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIpTION OF WORK ��� e, � I � j i rC� ��t t t' w/�,S a s �• ,� �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 20_ 06 AS _� HANDBOOK N T"3 3r
Equipment Installed MFG: ��Lp O i MODEL: N X /.� SIZEBTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
_A/C $25.00 �FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
_AIR TO AIIt EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS tJNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 �GAS PIPING $10.00 VENTILATOR $15.00
Number of fixtures @ $10.00 � x $10.00 = $�l D, �
Number of fixtures @ $15.U0 � x $15.00 — $ , s
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 x $35.OQ = $
State Surcharge = $ 5.00
MINIMUM FEE $40.00 Tota1= $ D . !1V
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 pemut 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 c which r� uires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME /� �(/ � i) �/ S�� DATE �/,? 2
APPROVALINSPECTORSSIGNATURE DATE
PLEASE NOTE: SEPARA'FE FERMITS ARE RE UIRED FOR BUILDiNG, EI,ECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977