P - 42741Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX �eFEC�rtve �-1-zoio
SITE ADDRESS �
'Cl�{IS APPLICAN"C 1S:
PROPERTY
OWNER/
TENANT
"tV
C_ ' . � f�"
❑ OWNF.;R
NAME: lu., l �I �
�1DDRES'`S]: �
PF{ONE: 1l�7-/ IY
CONTRACTOR COMPANY NAME:�
CONTACTPERSON•
YOUR E-MA[L ADDRESS
� CON7'RACI'O R
CITY
Permit No.
Received By: � Y�
��$�;�UN 2
STATE ZIP
SUBMI'I' A COPY OF
YOUR STA'I'E ��� S(��)� r f J��P �`�-'I CITY � S i�7'H'' �
LICFNSE WITH �' � �
APPLICAT[ON pHOri��L-�1'�'��'� �, J��J� FAX
PERMIT TYPE
TYPE OF WORK:
�SINGLG FAMILY ❑ TWO FAMILY
❑ rrr:w �KrNi.acFMFN�r
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
� AL;I'FRA"I'[ON/REMODFI.,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEF'T WHERE NOTED. FIXTURES: (INllICATE TO'1'AL NIJMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUA J 2�RAE HANDBOOK. (} ��/�
Equipment Installed MFG: MODEL: K �� S[ZEBTU YW ��0�
MFG: �_ MODEL: �", ' �'�"1 SIZE/BTU d �
MFG: MODEL: SIZE/BTU
✓A/C� $25.00 F[REPLACE (GAS) $15.00 GAS RANGE)OVEN $10.00
_AIR TO AIR EXCHANGEER $15 �FIRGPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $t0A0 ��
CH[MNEY L[NF,R $'10.00 GAS URYER $10.00 POOL HF.A7'ER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 _VENTILATOR $15.00
T'HIS IS AN APPLIGATION FOR A PERMl7'-NOT VAL[D UNT[L P20CESSED
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 applicatic�n for a permit and work is not to start without a permit; that the w�rk will be in accordance wiCh the
approved plan in the case of 11 ork which quires review and approval of plans.
SIGNATURE OF APPLICANT "�`�=�F+1 �i1LN 1�/Wv/ ' PRINT NAME �,� ICJ��I V IiM 1 W �AC�(vATE l!� ��f- �
APPROVAL INSPECTORS SIGNA�I'URE
� Cit� of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977