P - 41785Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � I J � �
SITE ADDRESS � �!� � S
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201 ]
YOUR E-MAIL ADDRESS �aY"Y��'�-i� � d
❑ OWNER �CONTRACTOR
ADDRESS:1 �a� � � � �
PHnNE �XQ� ' c�lfLi ` J % � S
Permit No.:L��
Received By:�'
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LS:�+l�l
ATE j�i�1VZ1P�� 3.3
CONTRACTOR COMPANY NAME: � 1
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # OS� �� - I�} EXP DATE a- � I
LICENSEWITH ADDRESS: S�S �O,�r'� �('L CITY S�' O�.R.J�� STAT�Ii�ZIP�I
APPLTCATION pHONE I'l�S I-o� � S^QO1 � FAX � I� a�% "��
PERMIT TYPE � SINGLE FAMILY O TWO FAMILY
TYPE OF WORK: O NEW i�REPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
D TAILED DESCRIPTION OF WORK �,..�,6`�p�\� Q���c, �T� G�P�"i�' %C�jUQO ��� �QOC�C��'rl�,'
�V��c �\c� C�
FEES ARE BASED ON 510.00 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/BTU
MFG: MODEL: SIZEBTU
' MFG: MQDEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
�AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOB) $35.00 NEW GAS GRILL $10.00
�BOILER $35.00 �FURNACE $35.00 GAS UNIT HTR $10.00
�CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK $10.00 _GAS PIPING $10:00 VENTILATOR $I5.00
�
�M�NIMUM F'EE'$40.Oii� Total.� $� �} �.�� �^
THIS IS AN APPLICATI�N 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 whio� requires review and approval of plans.
SIGNATURE OF APPLICANT _ PRINT NAME�����j,.T_DATE � J�
•-T-
DATE w��
�J City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977