P - 35838Building
Inspections
763-572-3604
763-502-4977 FAX
DATE Q,� �/ I 1
SITE ADDRESS � � _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WTfH
APPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS l�Y
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❑ OWNER �iCONTRACTOR
NAME:�� \ f � �1�� aC"
ADDRESS: � I � l(J� Y�- L'�OV-�1 ��CI
PHONE: � �p�` �W �f �t 1� '�
COMPANY NAME: i�N�YI �Y
CONTACT PERSON: �
STATE LICENSE # �'� ` EXP DATE
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PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEW �REPLACEMENT
DETAIL D DESCRIPTION OF WORK
d.� � CP-��l' C�r`ti
Permit No.:
Received By:
D�t��'��
� �1�• CITYy`� �CJ�I.�-� STA'
FAXli� � ����—�c�`�
❑ TOWNHOUSE
0 ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUA J 2006 SHRAE HANDBOOK /�
Equipment Installed MFG: ����0�� MODEL�M� SO7O3 Tl � SIZFJBTU �C�00
MFG: ��r��1i1 MODEL: i OoZy � SIZEBTU '�' ��OY`
MFG: MODEL: SIZE/BTU
�A/C 525.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER 535.00 I 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 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 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 work which requires review and approval of plans.
SIGNATURE OF APPLICANT , PRINT NAME� DATE � (
City of F'ridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977