P - 42757Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE i-�-zo,o
DATE /rj
SITE ADDRESS
THIS APPL[CANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
❑ OWNER
Permit No.� ��/(v.
Received By: "
D���'���E� 1 Q
NAME: Gt„t d 1�--v
ADDRESS: �7 p � —' � � �
I� �£ c�� I� t' 1-2 sTArE%�l iP v�'S� /,
PHONE: YJ � `U �
COMPANY NAME: �C.-CiC�,.✓ G(�
CONTACT PERSON: l� /�--
STATE LICENSE # EXP DATE
ADDRESS: �J�� iUn- i`�' !`-^"� CITY �L{'�STATt� �I�IP �
PHONE 7�d �j"� 7S—Zf"'�C.1t'}.0 j F
SINGLE FAMILY ❑ TWO FAMILY
❑ NEW EPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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 2006 ASHRAE HANDBOOK
Equipmenf Installed MFG: MODEL: SIZE/BTU
MFG: �' MODEL: �CO SIZE/BTU LO�� Uv C�
MFG: MODEL: SIZE/BTU
A/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 UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $]0.00 GAS PIPING $10.00 _VENTILATOR $15.00
Number of fixtui
�
(MINIMUM FEE�$35.50) Total �- $ , � �� �(/
THIS LS AN APPLICATION FOR A PERMIT-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 cod�s of the City of Fridley and with the Minnesota Construction Codes; that [ understand this is
not a permit but only an application fo pe mit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all w,pr ic qu'res eview and approval of plans. �
SIGNATURE OF APPLICANT ,-^ ^ PRINT NAME L(� Y' i(LQ 0�4•4�! Yx1Ci�'�'� I� �D �
I�
APPROV
ni .
DA
j`` " City of Fridley
Buil�ing Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977