P - 42228Building MECHANICAL permit Ivo.:�„i;� 1' ��`� �
Inspections RESIDENTIAL APPLICATION Received By: :'-''
763-572-3604 CITY OF FRIDLEY D���'�" `� �;�
763-502-4977 FAX EFFECTrvE �-1-zoio
DATE p J��� �D YOUR E-MAIL ADDRESS /"�I��'t C7/tJ /D3� I'KA` � C d
STfE ADDRESS �T� C✓ � �
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY NAME: � <<tJ
ENN�N� ADDRESS: / S� CITY /C%ic� C STATE�ZIP��a
PHONE: �l� -3y3'�� �
CONTRACTOR COIvtrArrY NA�: � � t '
SUBMIT A COPY OF CONTACT PERSON: � � f�S'OU �A I UUSoN
YOUR STATE STATE LICENSE # EXP DATE
LICENSEWITH �DRESS: Jr��� /��9RIPf �/�/V� CITY�/�����I�C STATE�LIP_,�30�
APPLICATION pHONE �6,� a?.TS� - y�'.3r� Fax
PERMI•I• •i•YPE BSINGLE FAMILY ❑ TWO FANIILY ❑ TOWNHOUSE
TYPE OF WORK' � �W � �P�CEMENT E�ALTERATION/REMODEL
DETAILED DESCRIPTTON OF WORK �it�'S7'I9/� q�g ��,.rG �� �y/S i:c�S�/� %RJ�O t'.�iS���
L✓ '<
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NQMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
EquipmentInstalled MFG: ����� MODEL: �%302 StZE�_. �3�,G'L?�
MFG: MODEL: SIZFJBTU
MFG: MODEL: SIZEBTU
A/C $25.i10 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $t0.00
AIIt TO AIR EXCHANGEER S15 FIltEPLACE (WOOD) $35.00 NEW GAS GRII.L 510.00
TBOILER $35.00 FURNACE $35.00 _GAS UNIIT HTR $10.00
�CHIMNEY LINER $10.00 GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTII,ATOR $I5.00
� 't#Pk1�'tl��'lJC�iC'CS � �If�.Q{� 1C ���.� = �i + ' >' ±h.',a x,;;
Number of fixtures @ $15.OU � x $15.OU = $ �c� , �
Number of fixtures � $25.00 x $25.00 = $ ,
Number of fiatures @ $35.00 x $35.00 = $
State Surchazge ° $ 5.00
MUM FEE $40.00 Totat = $ . �
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 Fridiey and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for permit and ork is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all wo ich r ir e' w and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME �RSO� �14I VFj^$O� DATE, � �}D I d
APPROVAL INSPECTO IGNATURE DATE
PTW+EA5E i►iUTE: $EP1�IRATE �EI�iVIIi'S A1tE RE FUR B'i7IC.,UI1'3G, F�L,E�,'TAI` G'`A�.. AIrT� ;k�:': . :,>�.;
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977