P - 60288Building
Inspections
763-572-3604
763-502-4977 FAX
DATE "L � o� j 1 pl
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
suB�T a copY oF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
� OWNER
NAME: '� �
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PHONE:"Z(43_ TZG
COMPANY NAME: f'1
CONTACT PERSON:
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YOURE-MAIL ADDRESS �XV1CQ, �C�� i�CYJi'Y1�Mn • �'Qrn
�CONTRACTOR
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STATE LICENSE # EXP DATE
AnDx�ss: l� �'10 �.v� �, i(11� ci� � 0.-
PHONE�(�3'��J3'�QCDo�J FAX�LO��'1c`�3'�� I�
�SINGLE FAMILY ❑ TWO FAMILY
� NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
O TOWNiiOUSE
❑ ALTERATION/REMODEL
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NiJMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK. ���,
Equipment Installed MFG:'TC'0.,t1Q� MODEL: i�,�_ SIZE/BTU ��VL?v
MFG�Ci'Ov(\!L, MODEL: XL l S1ZBB'I'[J
�C,: MODEL: SIZEBTU
LIA/C $25.00 _FIREPLACE (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 $10.00 _GAS PIPING $10.00 _ VENTILATOR $15.00
THIS IS AN APPLICATTON FOR A PERNIIT-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 o all work which requires review and appmval of plans.
SIGNATURE OF APPLICANT �/w\tTV`� Y7{ v�.�' PRINT NAME (��YYi LZUL1C.+ ��, l� DATE
AL
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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