P - 84389Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �D i'' I�^ ZO I�
SITE ADDRESS '
THIS 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
_ EFFECTIVE 1-1-2412
� �, '� �i $°1c/i., !
❑ OWNER
NAME:
ADDRESS:
PHONE:
COMPANY NAME:
_ YOUR E-MAIL ADDRESS _,�
�ONTRACTOR
CITY
%��^Cd' .A.�� /AN��
Permit No.:R�� Ia"'b��l(�
Received By:�'�
�'�R���° � �
eS'�"!
ATE ZIP
CONTACT PERSON: _,M t G ti R C[ j('rq t� S GT�
STATE LICENSE # EXP DATE
ADDRESS: � 7� $ js ��' L/" .ti !� CITY ��4 r''L S< S/ STATEh NZIP SS'�o3
PHONE
�S[NGLE FAMILY ❑ TWO FAMILY
�1 NEW "�REPLACEMENT
FAX
❑ TOWNHOUSE
❑ ALTERATION/REMODE�,
DETAILED DESCRIPTtONOF WORK .�vcw ��kNacE,,4/t n°���h�E�,,c,,,rt �.¢{h �':�,,,f / ��j� /�vy � lef/a R�-v
a/4YriY /r.t�. �� fo�+/3G�'� 'c+r A'� ".�. f.4/TE� 14�luscr�{ vt� / S�'rLtS
.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (tNDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HAIVDBOOK.
Equipment Instailed MFG: JpA�1,� MODEL: ����ir/o �m SIZE/BTU 76/�`�
MFG: ��'%i�� I�S�N MODEL: ,3N Z� X�C SIZEBTU �'�'t��
�A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
_CHIMNEY LINER $10.00
_DUCT WORK $10.00
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
j�FURNACE $35.00
GAS DRYER $10.00
_GAS PIPING $10.00
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $]0.00 �
GAS IJNIT HTR $10.00
POOL HEATER $35.00
_VENTILATOR $I5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D LJNTIL 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 APPL[CANT ��� PRINT NAME �.�G�i�4'��i /�� V S G�1 DATE �O �� S�'•�O I Z-
AL
TURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977