P - 35053Buildir�g MECHANICAL Pern�it rlo.- -�6
Inspections RESIDENTIAL APPLICATION Received By:�_
763-572-3604 CITY OF FRIDLEY ��''�� 2�
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE l/� i� C I YOUR E-MAIL ADDRESS cta�v 2� c{a.-v e.�, h eo�-% � fW c�r�.0�. r.�+ ✓1�,
SITE ADDRESS l0 2'] 1 y4 IaiL E Gi7 /J E
THIS APPLICANT IS: � ❑ OWNER I�ONTRACTOR
PROPERTY Nn�: R v.r+�_ _�j U fl �I �i �►J
OWNER/ .a,DDxESS: � 2'� I-A �L� �T _�.I f_ ci� F�'� D L£ Y s'ra'rFM_�1 ztr55'f 32
TENANT pHONE:�% (p �j ° �j % % " I (o �p �
CONTRACTOR COMPANY NAME: �A r/ E`�j �I E�k 7 f r�I G-t °�i-� 1 Je.
SUBMIT A COPY OF CONTACT PERSON:�M y M fi I> V i C�
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH �DRESS: J(a D/ �%`�' �A� �/� nI E CITY (`� L•�!aT Li STATE �1/J ZIP�S4 Z/
APPLICATION
PHONE'7/���j - %�0 I ' �� d / FAX
PERMIT TYPE �-SINGLE FAMILY ❑ TWO FAMILY � TOWNHOUSE
TYPE OF WORK• ��W y�EPLACEMENT ❑ ALTERATION/REMODEL
. �
DETAILED DESCRIPTTON OF WORK 2 E PL>! G� F v�2 ��'r �_. ��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOR�
PROVIDE AEAT LOSS CALC'S PER MANiJAL J 2006 ASIIRAE HANDBOOK
Equipment Installed MFG: L F_ nl ,J oT MODEL: .S LP`I �b � H!%"IO V 3(c$'p��EBTU� 7 y� % 0, 0 D t�
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
_A/C 525.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOII,ER $35.00 �FURNACE $35.00 _GAS UNIT H'I'R $10.00
_CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
Number of fixtures @ $10.00 ' x $10.00 = $ ' —
Number offu�tures @ $15.00 x $15.00 = $
Number of fixtures �a $25.00 x $25.00 = $ '
Number of f�tutes cr $35.00 i x$35.00 °$ �jcJ ,�
State Surcharge = $ 5AO
IINIMiTM FEE $40.00 Total = $ '`� � . l� ',
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 oniy plication far a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the c e o all wark which reyuires review and approval of plans.
SIGNATURE OF APPLIC ' \ �RINT NAME� l ,� � �C DATE \ ` 1 -
APPROVAL INSPECTORS SIGNATURE DATE \ "` I
PLEASE NOTE: SEPARATE PE ARE RE UIRED FOR BUII,DING, ELECTRICAL AND MECHAIVICAL WORK
Citv of Fridlev
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977