P - 39637Building
Inspections
763-572-3604
763-502-4977 FAX
DATE .� If
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY
O W t�-;
TENANT
CONTRACTOR
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
NAME:
ADDRESS: � U
PHONE:
COMPANY NAME:
Permit No.:
Received By:
Date Rec'd:
. � � IL ADDRESS ��($V�j�O(..)(�j �h'F� Q�QL: 1.t�61'7
�CONTRACTOR
_P. C e �^1�
CiTI'
TATE ��IN ZIP
SUBMIT A COPY OF CONTACT PERSON: �'�' � Q� �
YOUR STATE STATE LICENSE # M�� � EXP DATE
LICENSE WITH ADDRESS: �S�(p a��luo•�,�5 CiTY � Z STATE,'/�ZtP �,� I
APPLICATION )/ �j��
PHONE ��� L� 7(0 `C 3�i � FAX '��Sv�� `E?�--! �x-
PERMIT TYPE
TYPE OF WORK:
�I SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTBRATI�N/REMODEL
0
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTLIRES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUA J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: ����d�o�� �� SIZE/BTU ��!%�
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
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK $10.00 GAS PIP[NG $10.00 VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appfy for a building permit and I acknowledge that the information above is complete and accurate; that the work wiil 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 d 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 re�ui� review and approval of plans. �.
SIGNATURE OF APPLICANT
AL
TURE
NAME ��9C'���1 � ���
DA
U City of Fridley
B�ilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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