P - 45838Building MECHANICAL Permit No.•
Inspections RESIDENTIAL APPLICATION Received By:
�63-s�2-3604 CITY OF FRIDLEY ����,�I-�-�-�-�-�.1
763-502-4977 FAX EFFECTivE �-�-zo�,
DATE S� YOUR E-MAIL ADDRESS
SITE ADDRESS �n �; .3 � c� ` 3- � Ov�y
THIS APPLICANT IS: ❑ OWNER �EONTRACTOR
PROPERTY NpME: ►�11¢r��s ���.t,,t�,,-
OWNER/ ADDRESS: �
TENANT --��s-1b 3t�� s' '"`� CtTV �nl(t.,� STATE �"'�/ZIP�y�
PHONE:�ta 3 =j "�1 �3� C;
CONTRACTOR COMPANY NAME: "�'1`,/�xt,�b }'\� �{�,,�
SUBMIT A COPY OF CONTACT PERSON: `�✓��., 'S
YOUR STATE STATE LICENSE # a(;,�ta.�y (� u EXP DATE
LICENSE WITH ADDRESS: �"� L`�1 ��,,�,r�e.w /Evz id C[TY yill.l.c STATE�IP �'9�11 j
APPLICATION
PHONE L� S( (n '�'j ( i'-( �. FAX
PERMIT TYPE �NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: �NEW ❑ REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRtPTION OF WORK �/�S'�,�i �^�7c5 �",1�� f„j �j-1, q,�� (�„�,S
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 NDBOOK.
Equipment Installed MFG: �4-�,� "ZC � MODEL: ��.e,�,,,� � 3�p t` � SIZE/BTU �� l� �
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MFG: MODEL: SIZElBTU
MFG: MODEL: SIZE/BTU
A/C $25.00 IREPLACE (GAS) $I5.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $ I 5 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 �GAS UNIT HTR $10.00
CNIMNEY LINER $10.00 GAS DRYER $10.00 `POOL HEATER $35.00
_DUCT WORK $10.00 AS PIPING $10.00 �V ENTILATOR $15.00
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THIS IS AN APPLICAT[ON 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 appli on 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 1 k which r 'fes review and approval of pla .
SIGNATURE OF APPLICANT PRINT NAME " ���"'�``� �� DATE N
APPROVALINSPECTORSSIGNATURE DATE
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977