P - 42119Building � MECHANICAL Pe�it Ivo.�..� ' "� ��� �
Inspections RESIDENTIAL APPLICATION Received By: '
763-572-3604 � ��� � � � �
763-502-4977 FAX CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE 1 D"�" � i I YOUR E-MAIL ADDRESS Li2y� SGi-fal �SCa GMA/L. CO/�i
SITE ADDRESS L�� �G ;��,_�...`! j /�,%E � (�/� /Ji J�f .S'S't•/ �2 (
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY NAME: 3�%.�.��l� SG H'G> i..T�
OWNER/ ADDRESS: ��( 6 c3 (Z•Q S> N,Fr CITY� STAT��/
L.1f'� r;/�IVZIPS��YoZ�
TENANT pHONE: l�G� I'�l "' 3O�' �' �s I q G
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH pDDRESS: CITY STATE ZIP
APPLICATION
PHONE FAX
PERMIT TYPE ��GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT �1;ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �,p��/VI�' i4i�"1}} QL,yM,pp� L'. :Z.�PL�t G� G7r►,i� i�iViEG
(,a„r' j` LE.T �Q�+() � r� S�'�9� L L., I NC. �J V�� 1 LA i k� ¢'"'�!
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVf�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
_A/C $25.00 FIItEPLACE (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 LJNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $]0.00 GAS PIPING $10.00 VENTILATOR $15.00
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UM FEE $40.{)0 �'ota� _ $ ��. �%%
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply far 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 ork is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work whi e uir eview and approval of plans.
SIGNATURE OF APPLICANT r���� PRINT NAME G�L E��I "� I I
APPROVAL INSPECTORS SIGNATURE DATE
��. �. <���� �T�: 5�"� . . AR� �� ° r ��'111�:�T.�II;D�NG EL� : ��1�1�`"�� .. ..., �:
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977