P - 42740Building �� �`'�' MECHANICAL Permitivo.:`�% ���;� ���°�
Inspections RESIDENTIAL APPLICATION Received By: ��" ``+
763-572-3604 CITY OF FRIDLEY �� ��'� �� � ����
763-502-4977 FAX EFFECTIVE I-1-2010
DATE l�' —I ' � � YOUR E-MAIL ADDRESS � (lcc7 �v,� �C�C ��e-�'�C" i (lC'^ � ClJ�
SITE ADDRESS ( ZyZ �JT N •� -
THIS APPLICANT IS: ��� ❑ OWNER �fCONTRACTOR
PROPERTY NAME: � AtJ 1(,� (�Ri�.N D`� j�
OWNER/ ADD�ss: ly�A \Zl9 � H t..� IV •l.t� , C[TY
TENANT �� AP iD5 STATE�►U ZIP �JS
PHONE: LplZ-�� ° `��
CONTRACTOR COMPANY NAME: �LAR�Z, �`li H'j f NC7 � A� C. .Ll�% •
SUBMIT A COPY OF CONTACT PERSON: u'+�Ul..�c. YORKS
YOUR STATE STATE LICENSE # M� ZrJZ�3 EXP DATE �^ C7..� ° iO
LICENSE WITH ADD�ss: q3o3 C�1-YMali 1 t-i A�`L. �. CITY �jUL�,�j �1#il.L�,H STATEI'll� ZIP 'rJ�v�Z...�
APPLICATION PHONE �' �U3- 5�i'Z„� � ��t lQ FAX ��gc,� " cS�-I^L.' a �O I
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �REPLACEMENT ❑ ALTERATION/REMODEL i
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DETAILED DESCRIPTION OF WORK ��
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FEES ARE BASED ON $10.00 PER FIXTURE, EYCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: CARQI�t,� MODEL: S� �NDXOID� SIZEBTU ��0��
MFG: GAr61SC..R.. MODEL: Z�{A��fJZti] SIZE/BTU �-TON
MFG: MODEL: SIZEBTU
�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 iJNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT W ORK $] 0.00 GAS PIPING $10.00 VENTILATOR $15.00
Number of fixtures @ $10.00 x $10.00 = $
Number of fixtures @ $15.00 x $15.00 = $
Number of fixtures @$25.00 � x$25.00 =$ 7 J O°
Number of fixtures @$35.00 � x$35.00 =$ c�'j°°
State Surcharge = $ :50
MINIMUM FEE �35.50) Total = $ (QC� ,
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 o work 'ch, uires review and approval of plans.
i � t1 /�
SIGNATURE OF APPLICANT PRINT NAME �C.� � IS � p DATE �' 'l '�" I V
APPROVAL INSPECTORS SIGNATURE DATE ��`�. L�
PLEASE NOTE; SEPARATE PE I ARE D FOR BUILDING, ELEC RICAL AND MECHANICAL WORK
f i4v nf FrirliPv
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977