P - 42167Building - �
Inspections
763-572-3604
763-502-4977
DATE � o'
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
,
CONTRACTOR
SUBMIT A COPY C�F
YOLR STATE .
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
AX
���
MECHANICAL
:�
RESIDENTIAL APPLICATI�N
CITY OF FRIDLEY -- �
EFFECTIVE 7-1-2010
, . . YOUR E-MAIL ADDRE5S
❑ OWNER
COMPANY NAME: � 9 U� 1 r v►
CONTACT PERSON: � �
STATE LIC �[N]S �# '' EXP DATE �\�
ADDRESS: �1� CITY ►lJ
PHONE � FAX
INGLE FAMILY O TWO FAMILY ❑ TOWNHOUS�'
❑ NEW 0 REPLACEMENT ❑ ALTERATION/REMODEL
Permit No.:�(.-()Q G�
Receiv�d By:�
D����lAR 0 3 201 �
STA'
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACIi BE OW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZElBTU
MFG: MODEL� SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $]0.00
AIR TO AIR EXCHANGEER $IS FIREPLACE (WDOD) $35.00 _NEW GAS GRILL $10.00
_BOILER $35.00 �FURNACE $35.00 GAS LJN1T HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
AUCT WORK $10.00 GAS PIYING $10:00 _VENTILATOR $I5.00
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 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 f a permit a work is not to start without a permit; that the work wili be in accordance with the
approved plan in the case of all work 'ch re' roval of plans.
�---. � a �
SIGNATURE OF APPLICANT PRINT NAME DATE
APPROVAL INSPECTORS SIGNATUR , DATE ,
`-' City of Fridley �
ilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977