P - 46282Building MECHANICAL Permit No.•
Inspections RESIDENTIAL APPLICATION Received By:_���
763-572-3604 CITY OF FRIDLEY vat��:�..������
763-502-4977 FAX EFFECTTVE i-t-ZOii
DATE �" ��—� ( YOUR E-MAIL ADDRESS q�J�- ��P n n n� _+i� �1e, �`.i a�+o.` i• Gc�.�,
srrE Anv�ss Sy 3 D �'�'�' tS� A?� ��
THIS APPLICANT IS: ❑ OWNER CONTRACTOR
PROPERTY N�: S;AZLV.,9 i lo:� rA-R,i'�,�
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR co�arnrx.�[E: VE , .- �
SUBMIT A COPY OF CONTACT PERSON: � i� S'Z c rr�= v'^�'
YOUR STATE STATE LICENSE # (�v I 2 R-P•�^� EXP DATE I 2— r3 )"('L
LICENSE WITH �DRESS:�� % I��`�LN i1Jk% CI7'Y _STATE�IP t 3a3
APPLICATION pHONE %(, 7-3�,�• C,.i7p� FAX
PERMIT TYPE � SINGLE FAMTLY ❑ TWO FAMILY �TOWNHOUSE
TYPE OF WORK• � �W 0 ��ACEMENT �ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK w'f" 1% '� i.� a�
FEES ARE BASED ON SI0.00 PER FIXT[TRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOR�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipmeirt Installed MFG: MODII.: SIZEBTU
MFG: MODEL: STZEBTU
MFG: MODII.: SIZEJBTU
A/C $25.00 iFIREPLACE (GAS) 515.00 GAS RANGF/OVEN �10.00
AIR TO AIIt EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL SI0.00
BOILER $35.00 �FURNACE $35.00 �GAS UNIT HTR S 10.00
HIIuIlVEY LINER $10.00 GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
�' t�'�tilt'�s � �l#i:t�Q � ��4� *�•��,.;,w,.„,; ' �;
�Tttmb�o�fi�€ture,s (p� $1S.UA x Sl� C!0 � '
Number esf fiactures (a� $25.U(! x$2S Ot? ;B ::
T!�Tumb�r of fixtvres (c� $�5.� � $�5.� — $
State �u�charge = , $� S.Ut}.
FEE �#O.tlt! T�ta� _ $ �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is comptete 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 applicaf or 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 all ich requires review and approval of plans.
SIGNAT(TRE OF APPLICANT PRINT NAME� �—1 �,.,A'I��-F��
APPROVAL INSPECTORS SIGN DATE
�A,�'B �T��: S�FARA'�, �I��+� AR� , , �E'pR 8�3��i�rs � �'"""����L �. ���
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977