P - 42146Building
Inspections
763-572-3604
763-502-4977 FAX
DA'IE��
SIT'E �DRESS
TI-IIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT[VE 2-19-09
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❑ 0�1'NER
ADDRESS:
Penrut No.:
Recei�-ed By
COn1PAN1 N,�.I�fE- v�an�aa�aa � �cc.u��y .,� ... ................. .. —
CONTACT PERSON: Ym0
STATE LICENSE t€ F 17 �R7d_7� DATE
ADDRESS:
PHONE
F?�I�IILl" ❑ T��O F.Ah9I,1"
❑ NE�L' �EPLACEA•tENT
DETAILED DESCRIPTION OF WORK
GITY
FAX
❑ TOWNHOUSE
❑ ��ERATION/REMODEL
TE ZIP
FEES ARE BASED ON S10.00 PER FIX7'URE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAI. NUMBIIt OF EACH BELOWj
Equipmeat L►ata(led MFG: MODEL: SIZFlBTU
" MFG: ,. l" � v l MODEL: __�� � SIZF/BTU �s
y�. MFG: MODEL: ll� SIZFIBIV L/
`n,A/C 525.00 ACE (G ) 515.00 _GAS RANGE/OVEN 510.00
AIIt TO AIIZ EXCI�iANGEER S15 FI LACE (WOOD) 535.00 NEW GAS GRII,L 510.00
_BOII,ER 535.00 �FURNACE 535.00 GAS UNTf FTCR 510.00
Ci�bII�EY LIIJER 510.00 _GAS DRYER 510.00 POOL HEATER 5i5.00
DUCT WORK 510.00 _GAS PIPING 510.00 VENTII.ATOR 515.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
�Z.�
I herebt� appiv for a building pemiit and I aclaion ledge that the information above is complete and accurate; that the ���ork will be in
conformance �uith the ordinances the City of Fridley and �t,ith the Minnesota Construction Codes; that I understand this is
not a perniit bu y I a a� n a pe it and work is not to start �vith t a perniit; that the �vo � t�-ill be in acco ance w�th the
approved pl in the f a wo which quires review and approval of p s. �
SIGNATCTRE F P . PRINT N_�4E l
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977