P - 48641Building MECHANICAL Pe�it rTo.:
Inspections RESIDENTIAL APPLICATION Received By.
763-572-3604 D .� 'd��.,�'� � �
763-502-4977 FAX CITY OF FRIDLEY ���,� -
EFFEC'fIVE 1-1-2012
DATE � " � .3'f �' YOUR E-MAIL ADDRESS �+�� �v+ f ! �t ,y, p� 4 � 9 ' �d✓M
SITE ADDRESS � S 3.; T 3 •�� N G
THIS APPLICANT IS: ❑ OWNER j�ICONTRACTOR
PROPERTY NAME:
OWNER/ qDDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR COMPANYNAME: �NH�'�4�'oC. /KL��+(,.�.wi [4 / L G �-
SUBMIT A COPY OF CONTACT PERSON: ��� K�T 0 kN !�N
YOUR STATE STATE LICENSE # M���0�% EXP DATE �O O� 11 I i
LICENSE WITH ,qDDRESS: �7lf! % Or� µ A%W CITY k�J�CV STATE ZIP
APPLICATION pHONE �I/ �- YI � a S� � � FAX 7(„�i .3 `,S �(� '� g 3�S
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �'Q,REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK ��Kw�6t �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZFJBN
MFG: MODEL: SIZEBN
_A/C $25.00 _FIREPLACE (GAS) $15.00 GAS RANGElOVEN $]0.00
_AIR TO AIR EXCHANGEER $15 fTREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
_BOILER $35.00 �FURNACE $35.00 GAS L1NIT HTR 510.00
CHIT�IEY LINER $10.00 GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK 510.00 GAS PIPING $10.00 VENTlLATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accwate; 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 applica.tion 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 wor � whic equires review and approval of plans.
�' ,��.Z.3'' /,�
SIGNATURE OF APPLICANT PRINT NAME�r'� /L � K� irl^ DATE
APPROVAL INSPECTORS SIGNA URE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977