P - 43632Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ` �,J � � � �
SITE ADDRESS � �
THIS APPLICANT IS:
PROPERTY NAME:
OWNER/ ADDRES
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE i-i-2011
1'
COMPANY NAM
CONTACT PERSi
STATE LiCENSE
ADDRESS:_�
AHONE
YOUR E- AIL ADDRESS
'.e�-E-- �� , �� l
�CONTRACTOR
b C�KG'lY�.'� �' = N � cirY
PERMIT TYPE �INGLE FAMILY ❑ TWO FAMILY
I°
TYPE OF WORK: d NEW ❑ REPLACEMENI'
DETAILED DESCRIPTION OF WORK
�
EXP DATE
CITY
FAX
❑ TOWNHOUSE
❑ AI,TERATION/REMODEL
Permit No.: Ga � 1��13�
Received By: `�
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STA
TE ZIP,
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 200b ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/8TU
MFG: MODEL: SIZE/BTU
A/C $25.00 FtREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NBW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $ iD.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK $10.00 GAS PIPING $10.00 V6NTILATOR $15,00
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D 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 work which r �res review and approval of plans,
SIGNATURE OF APPLICANT ��V �°�-' �� ['RINT NAME J..tf �ti�i V tv� �"��'V �G DATE � D- I 2j- Z�L r
APPROVAL INSPECTORS SIGNATURE neT�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX`. 763-502-4977