P - 42219Building MEC�IANICAL p�it No.� ��� � c��
Inspections RESIDENTIAL APPLICATIUN Recei�ed By: !�" �
7b3-572-3604 CITY OF FRIDLEY � R;�—�—�,'�-
76�—$�2-4977 FAX EFFECTTVE 7-1-2010
pATE YQUR E-MAtL ADDRESS ROG/FEGGEZ�l"1kE,�� GMA�c� GC�V►�t
SITE ADDRESS �S7 �� �s� pt1%E.
THIS APPLICANT IS: �OWNER OCONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
ADDRESS: 2 S? :��. le`tT� A'1« " C1TY
PHONE: �7G� — �i 7 i' '47yT1*
COMPANY NAME:_
CONTACT PERSON:
STATE LICENSE # EXP DATE
ADDRESS: CITY STATE ZIP
PHONE
FAX
pERMi.I. T'YPE �INGLE FAMILY ❑ TWO FAMILY � TOWNHOUSE
TYPE UF WORK: ��w � REPLACEMENT �ALTERATiONlREMODEL
DETAII.ED DESCRIPTION OF WORK �!/Df� N�W .�s_.D AfJC RT'rTIJRJ� V€l�ii" F+�12 'BAS�rf�lT`
'[2 G l.�.�t�C r
r
FEES ARE SASED OlV 528.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: {INDICATE TOTAL NUMBER OR EACE[ BELOt'�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASffRAE HAND800K.
Equipment Instaped MFG: MODEL: SIZEBTU
MFG: MODEL:
SiZFIBTU
MFG: MODEL: SIZEBTU
_,AJC 525.00 FIR£PLACE (GAS) 515.00 GAS RANGFJOVEI3 510.00
AIRTO AIR EXCHANGEER S15 _FIItEPLACE (Wt'K3D} 535.00 NEW GAS GRJLLSI0.00
BOU fiR 535.00 lFCTRNACE 535.00 GAS UfIIT H7R S 10.00
CE�NNEY L1NER 510.00 GAS DRYER Sl Q00 �L HEATER S35.00
DUCf WORK S10.00 _ GAS PIPING 510.00 ENTILATOR 535.00
THIS IS AN APPLICATION FOR A PERMIT NOT VALID UN'CIL PROCESSED
��
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work witl 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 applicatian for a permit and wotk is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all wor hich re ' es review and approval of plans.
SIGNATURE OF APPLICANT _ PRWT NAME �Ii�� �F•l�l�• 'L DATE� /�
APPROVAL INSPECTORS 5TGNA DATE ____.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
7b3-572-3604 FAX: 763-502-4977