P - 42159Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-5�2-4977 FAX EFFECTIVE 1-1-201 I
DATE__� _/_, �t
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
NAME:
PHONE:
❑ OWNER
E-MAIL ADDRESS
CITY
Permit No.t�.U�
Received By:�
��c��_
�° /, c� e •�
� STAT� IP
CONTRACTOR COMPANY NAME: � I%t-�.G�i / c..� �t'�-Q�
SUBMIT A COPY OF CONTACT PERSON: /��� %y%'il ,� �-y"` J
YOUR STATE STATE LICENSE # O✓��Q" EXP DATE
LICENSE WITH ADDRESS: ��, � .. ��/1"y1J2O/�/ �jY CiTY/%1;i��A�! /�44/STATL��VLIP /
APPLICATION p�ONE � ����� �_ FAX �r
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSB
TYPE OF WORK: � NEW ❑ REPLACEMENT �ALTERATION/REMODE[.
DETAILED DESCRIPTION�OF
�%.v'�1._ �f�A�s.. �.,. �
a � h�' L. � /'in
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: {INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZEBTU
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
C IMNEY LINER 510.00 GAS DRYER $10.00 POOL HEATER $35.00
�UCTWORK$10.00 .� _GASPIPING$10.00 �VENTILA'fOR$I5.00
THIS IS AN APPL[CATION 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 F.ridley 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 re u res review and approval of plans.
SIGNATURE OF APPLICANT �/��%��i�" /�� PRINT NAME ,�%� l` /Ilr�`�! �`i�' DATE � j�� Q�I �
AL
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977