P - 42188Building MECHANICAL Permit No.•
Inspections RESIDENTIAL APPLICATION Received By: L
763-572-3604 CITY OF FRIDLEY � �'��
763-502-4977 FAX EFFECTivE �-i-ZOio
DATE l Z% '3 I/ C YOUR E-MAIL ADDRESS �� "v �? �1 G�a v� S{�o u;� i/�a /�l- yC l.� GZ l{/' •(�L*yy�,
SITEADDRESS 3 �� - E �E
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY N�: c, G H� R R E�i ��C-� f� f1, -t-1 L
� N�T aDD�ss: I I'1 5 3�L a�t v F. �•1 � ci� �� 1 D t E`i' srATE,N� �I zir5��21
PHONE: �7Lo�i � ��'1 Z ' � 7 ZZ`T"
CUNTRACTUR co�.�rrY rr�: D�t,�/ E�� F�t T I� C� �--�'r 1�-
SUBMIT A COPY pF CONTACT PERSON:�,M � M��\I ��,�
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH �DRESS: l(� O 1 31 �` �1 �� E- ' CITY (11 L• j'1 C1TLi • STATE IV _I�ZIP��-'-��
APPLICATION PHONE '% b'�="j�j I—(o°l U l FAX
PER11�fIT '�'YPE � SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: �� ❑ �PLAGEMENT ❑ ALTEI�TION/ItEMODEL
DETAII,ED DESCRIPTION OF W(7RK t
FEES ARE BASEl? ON $iQ.QO PER FIXTURE, EXCEPT WHERE NDTED. FI7�TLTRES: (INDICATE TQTAL NUA�BER OF EACH BELOW}
PROVIDE HEAT LOSS CALC'S PER MAN[JAL J 2006 ASHRAE HANDBOOK
Equipment Instalied IvIFG: L�nl ���f- MODEL:[�Lo l M P- �R� ' U-7l ' ��1 SiZEBTtTq 5% 1 D, 0 UO �j7U
MFG: MODEL: SIZEBTU
M�'G: MOIIEL: SIZE/�TU
AlC �25_00 _FIREPLACE (GAS) $15_00 _GAS RANGE/OVEN $1Q.00
AIR TO AIR EXCHANGEER $IS _FIREPLACE (WOOD) $35.00 NEW GAS GRILL �10.00
' ' �BOII,ER �35.00 �FURNACE $35.00 GAS UNIT HTR $10:00
CHLA4I�IE�' LIIa1�R $.L�_l� Ci� I��.3�ER,$,10:QD P�QL. L�r1�ER S3S=f�9-
�DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
�"+��'A���1.'�S � ���#.� ����:� � +� � , x
NumtibeT of�tt�res �a �15:t)(i x �$15.�1'= $
Aiu�her €�f fix�xres � $25.4�0 x'$25.�'= $
1�#umber af fixtures @ $35.OQ � x $35.(?U = $ ��,1�
S�ate �urcharge = $ 5.fi0
FEE $4fl.U0 Tota1— $ �� �l�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJN'TIL 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 ihis is
not a permit but only an pp 'cation 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 c of k which requires review and approval of pl s.
S�!'a1�T�4.'TU� ?Q�F A�PPLICAI�I \ ' ER.LN,'L t+Id�,AQE � IIA"L� `��""��_ .,
, � ��l
APPi�flVAL INSPECTORS SIL'iNATURE DATE
Pi.�.�. A��IT�: S�EP,AB.PL'T� �' A�E: F�L?R. '''�ff�;. :
City of Fridley
�iui�ding �nspe�tions i��partment
6431 University Avenue NE, Fridley, MN 55432
3fi3-�'7`i-���� �'A�: '�fi�-�fiZ-��'7"7.