P - 42216Building
Inspections
763-572-3604
763-502-4977 FAX
MECI-3ANICAL
RESIDENTIAL APPLICATION
CITY O�' FRIDLEY
EFFECTIVE 7-1-2010
DATE ``7 - 01 ?- � U YOUR E-MAIL ADDRESS
SITE ADDRESS /3S a "�S �'�- Q V L �� F� i�t �
THIS APPLICANT IS: ❑ OWNER ,�CONTRACTOR
Penmit No.: `' � j ,� l�
Received By:
�
Date Rec'd:
REC'D �,�-�
PROPERTY NAME: Ka�-�, i� �,,� Fi� ��e.�
OWNER/ qDDRESS: l35U 'I� �'�- `Q�� wC CITY F12.ro1�� STATEi7NZIP
TENANT PHOt�rE: (� � a, S l 7-'� d a�
CONTRACTOR COMPa1�rY NaME: (lc �. ,. C� Cti S ti e �(- ���o- (
SUBMIT A COPY OF CONTACT PERSON: C?h i� s � R,io �.o
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WTTH q�DRESS:�d�l� /—j4-tM S4 *+�--`• CITY �Mtr.I��� STATEM�*` ZIP�'s�_L
APPLICATION pHONE "7 �► 3 7 S�i' a � G 9 FAX
PERMIT TYPE
TYPE OF WORK:
i�.SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �EPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �,6(,A (1 �' �,n(� ��,�-t„�-•�- ,�}r �. �ohd r htcth��-
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUi�IBER OF EACH BELOW)
PROVIDE FIEAT LOSS CALC'S PER MANUAL J 2006 ASIiRAE HANDBOOK
Equipment Installed MFG: Co- �R� A a�. MODEL: a�'I �4 CC b i- �F SIZEBTU � � ��
1 A/C $25.00
AIR TO AIR EXCHANGEER $15
$OILER $35.00
CHIlvINEY LINER $10.00
___DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
_FIREPLACE (GAS) $15.00
_FII2EPLACE (WOOD) $35.00
_FURNACE $35.00
_GAS DRYER $10.00
GAS PIPING S 10.00
SIZE/BTU
SIZE/BTU
`GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
`GAS UNTT HTR $10.00
_POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work which requires review and approval of plans.
SIGNAT[JRE OF APPLICANT
APPROVALINSPECTORS
DA
City of Fridley
r � J 'C� �'A 1� I DATE �% � °7 ?' � e
�$ualding �nspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977.
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