P - 43886Building
Inspections
763-572-3604
763-502-4977 FAX
S[TE .-�DRESS _
TFIIS .�PPLIGANT IS:
MECHANICAL
RESIDENTIA,L APPLICATION
CITY OF FRIDLEY
EFFECTT�- E 3-19-09
�❑
PROPERTY N..�,�
OR'NER/
TENANT �Dx�ss:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
Al'PL[CATION
PERNIIT TYPE
TYPE OF WORK:
crri-
COAIPANI' N.�fE. •��a� wa� � i�ca�a �y an ..a .. ...�....... ..
CONT�CT PERSON: ym�
STATE LICENSE tk F 17 1R7d_7� DATE
ADDRESS:
PHONE
F;U�•IIL1' ❑ T'�'O FAI�,IILY
❑ NE�L' �REPLACED•fENT
DETAILED DESCRIPTTON OF WORK
FAX
C7 TO WNHOUSE
❑ ALTERATION'REMUDEL
Permit No. �?� ���o��i.Qa'
Received Bv:�
��:
�.,�
STATE ZIP
FEFS ARE BASED ON $10.00 PER FIXTiIRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACii BELOVI�
Equipment Inatalled MFG• MODEL: SIZEJBTU �---
MFG'��G�YY MODEL: Z O SIZF,BTU��V�O
MFG: MODEL: SIZF/BTU
A/C 525.00 PLACE (GAS) $15.00 GAS RANGE/OVEN 510.00
_AIR TO AIR EXCHANGEER $15 JFIREPLACE (WOOD) $35.00 `NEW GAS GRILL 510.00
_BOII,ER 535.00 ,�FURNACE 535.00 GAS IINTf HTR $10_00
Q-IIIvII�IEY LINER 510.00 _GAS DRYER $10.00 POOL HEATER �iS.W
DUCT WORK 510.00 _GAS PIPING $10.00 VEN77LATOR 515.00
THIS IS AN APPLICAT[ON FOR A PERMIT-NOT VALID [JN'I'II. PRO('ESSED
I hereby appl_Y for a building pernlit and I ackzio�� ledge that the information above is complete and accurate; that the «�ork �y�ill be in
conformance ivith ordin es es of the Citv of Fridley and �s-ith the Minnesota Construction Codes: that I understand this is
not a pem � ut applic• ion for pemiit and work is not to start «�ith t a perniit; that the i�•o -«-ill be in acco ance �vith the
approv plan � of work ch requires review and approval of p .
SIGNaI�L UFAPPLICA p�[.I'I'rl,�fE � ld j
L
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX_ 763-502-4977