P - 35282Building
Inspections
7b3-572-3604
763-502-4977 FAX
DATE 111"lll
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
, I C:11 � � 1i'
MECHANICAL
RESIDENTIAL APPLICATION
CITY 4F FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
- � .-: rTw� n� c;
❑ OWNER �CONTRACTOR
Permit No.:
Received By: � �° ti'�� N
Date Re�iaL� ...� U
� ��
rra�: � � � �-v �i � �' � � a � r �
ADDRESS: �� Y1•C._,.. � CITY STATE ZIP
PHONE: '�L L► �.• Z. Z��I "�� 1 L� �
COMPANY NAME:
CONTACTPERSON;
STATE LICENSE # � �—���
nDn�ss: alo la ��s�► �xs.t-c1.� I�?� crrY � sTA
PHONE 1 IO� �� 5 �-� e Fax �� 3-"7 5� - s� l
PERNIIT TYPE °�GLE FAM[LY ❑ TWQ FAM�..Y
M
TYPE OF WORK: ❑ xsw �ri.ac�vr
DETAILED DESCRIPTION OF WORK Ir
O TOWN!-IOUSE
❑ ALTERATTON/REMODII.
�F- �' � C
FEE5 ARE BASED ON 510.00 PER FIXT[TRE, EXCEPT WHERE NOTED. FIXTIJRE3: (IIVDICATE TOTAL Ni1MBER OF EACH BELO�
PROVIDE HEAT LOSS CALC'S PER MANUA J 2006 A5HRAE AANDBOQK. /�' A
Equipment Instailal MFG: MODEi.: �-f � N'1 ��I V SIZE/BTU
MFG: �,�n-�'� MODEL: �` x 13 �Z � SIZE/I3TU
MFG: MODEL: SIZE/BTU
� A/G $25:00 _FIItEPLACE (GAS) 515.06 _GAS RANGF✓OVEN $10.00
AIR TO AiR EXCHANGEER $15 F'IREPLACE (WOOD) $35.00 NEW GAS GRII.L 510.00
BOII.ER $35.00 =FURNACE $35.00 GAS ilNTf HTR $10.00
CHIIvII1EY LINE12 $10:00 _GAS DRYER SI0.00 POdL HEATER 535.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR SIS.00
�tiattbmr of �ixtu�es' �u �35.W x �35.f10 = � '
5tate Surcharge = $ 5.00
fMINIMUM FEE �40.�1 Total = S � �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pernut and I acknowled e tliat the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of th i' of Fridley and ' the Minnesota Construction Codes; that I understand this is
not a permit but only an app i' r erm' an o not to 'thout a permit; that the work will be in aceordance with the
approved plan in the ork w'ch uues r c and app I of plans.
SIGNATURE OF APPLICANT \ s-/'��'�R-S U�ATE�� �' ��~ l�
APPROVAL INSPECTORS SI NATURE � DA1"E G
�'LE�SE NQ"T'E. SEPARATEP RE UIR�D F(?R BUILDING '�LE MECEIANT�AL WORK
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
2���
� . . . . .. . r . . . . .
Y,•
r.. .. . . � . .. � . � .. . . . . . . .