P - 62704Building
Inspections
763-572-3604
763-502-4977 FAX
DATfi
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
1V�ECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRII)LEY
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❑ OWNER
YOUR E-MAIL ADDRESS
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ADDRESS: �`�""`�---"" y CITY
PHOI�B: � % Cv� . S % f�% � `/ �
_ _ _ ._ _
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COMPANY NAME:
CONTACT PERSON: Home Energy Center
- 2415 Annapolis Lane N #170
STATE LICENSE #_ Plymouth MN 55441
ADDRESS: 763-476-1990 fax 763-476-1143
PHONE FAX
�INGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
�
Pe:mit No:
Received By:
D��"�'y4�
ATE ZIP
ATE ZiP.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIAE HEAT LOSS CALC'S PER MANUAL J 6 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: fl� � u�^ MODEL: � I� G%S SIZE/BTU _�� [7
_A/C $25.00
AIR TQ AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $]0.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a bui(ding permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances ar,d codes of the City ef Fridley ar.d wi*.h the Minnesota Construction Codes; that I understand this is
not a permit but only an ap ication for �t a work is not to start without a permit; that the work will be in accordance with the
approved plan in the ase al ork w ich quir review and approval of pla s.
SIGNATU NT PRIIv'T NAME � + q � ��?�� /�ATE � � 1 • / �
TlIRE
DA
� City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3504 FAX: 763-502-4977