P - 42273Building
Inspections
763-572-3604
763-502-4977 FAX
DATE "1 ' �"'� "
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBNIIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE I-1-2010
YOUR
/
❑ OWNER +�CONTRA
Y�C f Y l Q J j�
S:
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COMPANY NAME�
CONTACT PERSON!�-Js� G
STATE LICENSE #��
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Q SINGLE FAMILY ❑ TWO FAMILY
❑ NEW - �'REPLACEMENT
DETAII.ED DESCRIl'TION OF WORK
EXP DATE
❑ TOWNHOUSE
0 ALTERATION/REMODEL
Permit No.
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.
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TATE ZIP
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (IIYDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S FER MANUAL J 2006 ASHRAE IiANDBOOK.
Equipment Installed MFG: MODEL: SIZEB'fU ���r�
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C 525.00 _FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIRTO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER 535.00 FURNACE 535.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK 510.00 _GAS PIPING $10.00 _VENT[LATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 ermit and work is not to start without a per►nit; that the work will be in accordance with the
approved plan in the case of all w ch requ' es e e and approval of plans.
SIGNATURE OF APP�ICANT A�2�����/C_.� PRINT NAMEP/.^.��J Gt/Ll_!LU Y DATE "1 ��
ALINSPECTORS
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977