P - 35746Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� �'" ��
SITE ADDRESS ��i
THIS APPLICANT IS:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
� OWNER J�CONTRACTOR
PROPERTY NAME:_
OWNER/ ADDRESS:
TENANT _
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Permit No.:
Received By: /�% 'V
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TA'i'E�/�1/ZIP �fy2/
CONTRACTOR COMPANYNAME: �Cf�i�l� /7�r��a,c�iea ��'dsii�F1
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SUBMIT A COPY OF CONTACT PERSON: �j�r/��-i.�/ ('y,��/W
YOUR STATE STATE LiCENSE #�9���/�J/,� EXP DATE ,� %%' 2 d/2-
LICENSE WITH ADDRESS: ZZ3 ��QN��S,a/r /�� CITY ��y/����f�� STATF�IAC�ZIP��Z
APPLICATION pHOTiE _7G.�� Z� �� ��' �'JJ� FAX ��� Z�� D�f%
PERMIT TYPE � SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: O NEW �REPLACEMENT
DETAILED DESCRIPTION OF W ORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TQTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MAIYUA J 2006 ASHRAE HANDBOOK.
Equipment (nstalled MFG: 4PP i f r MODEL: 5�����%� SIZE/BTU O pv v
MFG: �� MODEL ZI�1ND`.�v SIZE/BTU Z.,� T��t�
MFG: MODEL:
,�A/C $25.00 FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BO[LER $35.00 �FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
__DUCT WORK $10.00 GAS PIPING $10.00
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $ I5.00
TH1S [S AN APPLICATION FOR A PERMIT-N07' VALID LJNTIL 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 ap ' t�on fo a permit and work ' t to start without a permit; that the work will be in accordance with the
approved plan in the case all work ich r res r' w a approval of 1 s. � /")' 2 j
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SIGNATURE OF APPLICAN ' PRINT NAM D�/.?-/ (.t�.�!/�DATE O�� '� �
APPROVALINSPECTORSSIGNATURE naT�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977