P - 44459Building : MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 2-19-09
DATE 1 /�( 1"
SITE ADDRESS `�.3�
THIS APPLICANT IS:
PROPERTY
�WNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
AILED
�i
❑ OWNER
YOUR E-MAIL ADDRESS
Permit No.:
Received B,
Dat�'�1:
NAME: �kl �( �(�� 1 V(� l/ a�
ADDRESS: CITY STATE ZIP,
PHONE: � �P "' C'') � — �l L O �
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE # XP DATE �
ADDRESS: CITY ,� �TATE�IP
PHONE �I a �! !c �v �T FAX
C�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
�� Yv Oltl1
0 TOWNHOUSE
O ALTERATION/REMODEL
0
e
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL NUMBER OF EACH BELOW)
Equipment Installed MFG: MODEL: S1ZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $I5.00 GAS RANGE/OVEN 510.00
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 T�GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 _GAS PIPING $10.00 _VENTILATOR 515.00
0
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
confonnance 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 pian in the case of all ork which requir review and approval of plans.
SIGNATURE �F ArrLICANT �-(�9 �I/iL� PRINT NAME� n I �C`( ��� DATE��_
City of Fridley
Building Inspections Department
6431 Universiiy Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977