P - 41776Building MECHANICAL Perrnit Ivo.: (,,� -�
Inspections RESIDENTIAL APPLICATIUN Received By:
763-572-3604 CITY OF FRIDLEY �'���� �01�
763-502-4977 FAX EFFECTivE i-i-zoii
DATE��(.i �� YOUR &MAIL ADDRESS � I'! i� �. GO
SrrE ADDRESS ,� �}' / la �%' cS �`� /�%'L�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NAME:
OWNER/ �D�ss: ci� sTa� z�r
TENANT
PHONE:
CONTRACTOR COMPANY NAME: '}') � �
SURMIT A COPY OF CONTACT PERSON: ��.
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH qDDRESS: �s %,ZS oZ %7 � A✓/./�//.C> CTtY 1�,z �i � STATE�IP�,�,�D�y!!Q
APPLICATION PxorrE 7 L�- 4y,y -9�1c'.3 F� 7G 3-�fy�f -s �02. %
PERMIT TYPE �SINGLE FAMII.Y s�'WO FAMII,Y ❑ TOWNHOUSE
�G�
TYPE OF WORK: � �W ��P�'CEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIP'ITON OF WORK I Ct ��f
FEES ARE BASED ON S10.00 PER FIXTURE, EXCEP"T WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVf�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipmem Installed MFG: MODEL: SiZE/BTU
MFG: MODEL: SIZFIBTU
MFG: MODEL: SIZE/BTU
A/C $25.00 �FIItEPLACE (GAS) $15.00 GAS RANGFJOdEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35,00 NEW GAS GRIL.L $10.00
_BOILIIt 535.00 ,`,�FURNACE $35.00 GAS IJNIT HTR 510.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING 510.00 VENTII.ATOR $15.00
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�U[Ct�CY f1��liCCB"� ��.�i� X'���:� = �
Nwnber of fixt�rres @ $35.OU �'x S35.OQ = $��
St�te Survchazge = $ 5.00
` FEE S40.fi0 Total = $ "1'%f� �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN1'IL 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 ork which req ires r view and approval of plans.
SIGNATURE OF APPLICANT w � PRINT NAME � B DATE I �"" J'" �'
APPROVAL INSPECTORS SIGNATURE DATE �(./
�A�"E Nt�`I`i�: 'S3�Pt#i�ATE .412E R� I�+ �'3�.�.1.?�NCir E�.��`�I�.` . .
City of Fridley
Building Inspectinns Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977