P - 42168Building
MECHANICAL
Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
�63-s�2-3604 CITY OF FRIDLEY D 'I� '
763-502-4977 FAX ���
EFFECTIVE 1-1-201 ]
DATE ^ YOUR E-MAIL ADDRESS /1 �%�i � � e n�S • Lo
SITE ADDRESS S�U Y� � l� d S T j'V I-��-
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY NAME: R A� I/�- C,
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
COMPANY NAME: l 1 e h
CONTACT PERSON: PI1 i ��
STATE LICENSE # EXP DATE
ADDRESS:��Qg� !y CITY .uD/v� STATE�%'1
PHONE �IJ ���y �/ �lP FAX %6 �-5/3�/—QC�`7 t1
PERMIT TYPE � SINGLE FAMILY J�TWO FAMILY O TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT �ALTERATIONlREMODEL
DETAILED DESCRIPTION OF WORK �,'�g� �� ��,G( (J,�,,,,7`'y,,,s f> i� G�� g1�.�
�� n e c. %�o�
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 HANDBOOK.
Equipment [nstalled MFG: MODEL: S�Zg/g'fU
A/C $25.00
AIR TO AIR EXCHANGEER $l5
BOILER $35.00
CHIMNEY LIN6R $10.00
DUCT WORK $ ] 0.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
_ GAS PIPING $10.00
SIZE/BTU
SIZEJB7IJ
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
_VENTILATOR $15.00
THIS IS AN APPLICATION 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 application 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 al ork wh' r ui • s review and approval of plans.
SIGNATURE OF APPLICANT D PRINT NAME �/ I /LS� DATE �^� //
ALINSPECTORS
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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