P - 42753Building MECHANICAL
Inspections RESIDENTIAL APP�,ICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE /�- "/
SITE ADDRESS _Q
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
— �O
Q OWNER
YOUR E-MA1L ADDRESS
NAME: /�o ��+ �� � L.�vr
ADDRESS: 9 � ,?� �L � ..��"� �
PHONE: %b 3- 7���-�TT�
ci� . FS/�;
Permit No.:�`��
Received By:
Dat����d:' �" � .� �
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_ STAT�ZIP�
CONTRACTO COMPANY NAME: � � G �� / ��
SUBMIT A CO F CONTACT PERSON: /
YOUR STATE STATE LICENSE # p�.J(�� D/Y/�_ EXP DATE __ /� r' � �-' I�
LICENSE WITH ADDRESS: CITY STATE ZIP
APPLICATION pHONE FAX _
PERMIT TYPE I�NGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK /%�d�/
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
i %d .�/ti�P/ .�
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Instalied MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $I5.00 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 $10.00 _GAS PIPING $10.00 _VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 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 o Il w rk wh'ch r es review and approval of plans.
SIGNATURE OF APPLICANT �t/�------- PRINT NAME /� � DATE f d` ��/ "/�
APPROVAL INSPECTORS SIGNA
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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