P - 48320Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFEC�r►vE �-�-2oi2
DATE_ ��/ �(J� YOUR E-MAIL/�ADDRESS s z . �
SITE ADDRESS ��/ � y' I C_ /��� J j" /V �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
Permit No.: '� ��I�! l; � �
Received By: %
Date Rec' • � � L
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PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE: � �� " �l��� -- ��G /
CONTRACTOR COMPANY NAME: -/ 2✓'/ G�
SUBMIT A COPY OF CONTACT PERSON: _,�/'j///'�/'...-✓)
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: , CITY /�7�1-iyt L�F�� �. STAT@'l�ZIP�(L`�
APPLICATION pHONE / — � ' FAX S �e�1r
PERMIT TYPE
TYPE OF WORK:
DETAILED
O SINGLE FAMILY f�TWO FAMILY
❑ NEW ❑ REPLACEMENT
� � • �_,
❑ TOWNHOUSE
�ALTERATION/FtEMODEL ��� r +2
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: SIZEBTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $] 0.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
llUC'I «�ORK $10 00 GAS PIPING $10.00 VENTILATOR $75.00
�Iu�iiber affixtures �(c� $i0.0'0 - x $I(}.0� $ �
uml
:00—$
TH1S 1S AN APPLICATION FOR A YERMIT-NOT VAL1D 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 onlyJaa_.a ' tion for a ' nd work is not to start without a ermit; that the work will be in accordance with the
approved plan�case of all wor ic r ' es r view and approval of pla .
SIGNATURE OF A 'tCt1NT - - -- PR1NT NA f� �d�! � DATE � � �'� � 2
APPROVAL INSPECTORS SIGNATU DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977