P - 48572Buildin�
Inspections
763-572-3604
763-502-4977 FAX
DATE . � �^ I �'"� � I 7�
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
f}v� 1�/ �
❑ OWNER �CONTRACTOR
Permit No..'�UI d �0 n�i5
Received By:.L%�_
.�,`:ti,�,_ ,
.
ADDRESS:� Cs�`S� � �% �i �'` �^ C1'I'Y �i2^�TiG-fi, STAT�ZIP�
CONTRACTOR � COMPANY N
SUBMIT A COPY OF CONTACT PERSON: `-T ��' F- C-O A r S
YOUR STATE STATE LICENSE #��bD ` rn� EXP DATE �
LICENSE WITH pDDRESS: IaC�s � 6�(�E '� �'`' ��- CTI'Y�
APPLICATION pHONE �� - �b�F - � `I'''��S- FAX
PERMIT TYPE
TYPE OF WORK:
�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �AEPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
�
ATE�1l�'ZIP
DETAILED DESCRIPTION OF WORK �--z�+ �r1- /GYl9�t-
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/BN
MFG: �O�-^-� ` MODEL: SIZEBN I��! I���
IvIFG: MODEL: SIZE/BTU
A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGFJOVEN 510.00
AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) 535.00 NEW GAS GRILL $10.00
�BOILER $35.00 FURNACE $35.00 _GAS UNIT HTR $10.00
CHININEY LTNER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $]0.00 _GAS PIPING $10.00 _ _ VENTILATOR $I5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LRVT[L 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 applicatio 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 ' h r uir s review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAMEJ �� �� U�- �S DA� ( ��`� Z"'
APPROVAL INSPECTORS SI ATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977