P - 45757Building MECHANICAL permit Ivo.:
Inspections RESIDENTIAL APPLI�ATION Received By:
763-s�2-3604 CITY OF FRIDLEY ���'��"'� ���
763-502-4977 FAX EFFECTivEi-i-zo�i
DATE �� " �� YOUR E-MAIL ADDRESS J� � k� ��re.�'�'P-v Cn� 1r �iYl i�v� �� C ��
SITE ADDRESS �� C> � c...3 �' a�-�-
THIS APPLICANT IS: L7 OWNER �ONTRACTOR
PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR COMPANY NAME:�T � r � ti1 u� ✓�
SiI�3MIT A COPY OF CONTACT PERSON: Y�/1 \�� �a v o^ rn G� v�
YOUR STATE STA"1'E LICENSE # EXP DATE
LICENSE WITH ADDRESS: � �J � �^ I � �P �' �`" � �%�' � CITY� t L �� � ✓ STATEG�'l ZIP� c)t?
APPLICATION pHONE� �- ei ��` ' G��,C� FAX � �,� � ��Oa ' ��L �,� �
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY O TOWNHOUSE
TYPE OF WORK: � NEW �EPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK � -e,� �c.c,--� � �: `-�2..t
FEES ARE BASED ON $10.00 PER FIX`I'URE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVf�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Instalied MFG: MODEL: SIZFJBTU
�G:"���y►� MODEL: ` f�'I��L SIZE/BTtJ_���T_VV
Ng'(}: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $]0.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
�BOILER $35.00 _FURNACE $35.00 GAS tTNIT HTR $10.00
�CHIMNEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTII.ATOR $15.00
i"+�lli�' tt� �tXl'�7PS' �'.���.� ,�� 7C � �{�i� � �: . ` � `� a. .
�l�ii1�C Of �IX�#iI85 � $t�.�' X ���.� �''�
NiIICl�E;i Of �XiUC�S �R ';��S.QO X ��$.I�Q = $
Number Of fiactures @ S35;Q0 x$3S.OU =� '
State Scucharge = $ 5.00
MINIMUM F`EE �44,Q0 Total = $
i..-� (� '�.
TffiS IS AN APPLICATTON FOR A PERMIT-NOT VALID UNTIL PROCES9ED
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 all wo k w ch requires review and approval of plans.
SIGNATURE OF APPLICANT �C�v�'�fVIG'Y` PRINT NAME Iv `�� Wt-� � 0✓MGIN DATE ,�/Z7 /Z d J�
APPROVAL INSPECTORS SIGNATURE DATE
PLE:AS� 1tIUTE: SEl''ARATE PERMITS A1tE RE UIRED FOI� BLJILI�ING, ELEC"I'RTCAL AND MECHAI�IICA�, �f3KK
City of N'ridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: '763-502-4977