P - 48321Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX r....r„T.,,,r , , ��„
DATE�
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
""' �.� �i �'�i S % /l/�'�
❑ OWNER J�CONTRACTOR
Permit No.:
Received By:�����
Date Re�p i � � �� �- '- � � �
�' /�/,. �/ ,fl/Yl:��.� •
ADDRESS: CITY STATE ZIP
PHONE:� S I �^ 3. ^�� I
COMPANYNAME� D��rdl9✓ (O�A'✓Ld1 L��Ii/L{
CONTACT PERSON: �� (t1.��2r)
STATE LICENSE # EX/P� DATE / "
ADDRESS: f%�� � l�%/�C�,+t�'1 JT�/�/.��CITY /- /}Yl'1 Ls7-lC£' STATE�i�IP ���
PHONE % � - �!� •� �! �{�p l� FAX S��►�► �
❑ SINGLE FAMILY I�CCWO FAMILY
� NEW ❑ REPLACEMENT
❑ TOWNHOUSE
I�.ALTERATION/REMODEL JC Z��-i /�
DETAILED DESCRIPTION OF WORK (,.q� (_/��:,�.� 6�r� �6 GBIW � / ��/��r � �T 'k' ,fil�C
� 41�� 0a€�?.��iDri�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL IVUMBER OF EACH BELOW)
PROVIDE FIEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZEBTU
A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WOP�K $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $]0.00
GAS PIPING $10.00
X$1Q,�t3—$ -
x$]S.t?0 -$
ures � $35.40 �
SIZE/BTU
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $]0.00
POOL HEATER $35.00
VENTILATOR $15.00
�taie Surcharge — ' < $ 5.00
,Y� �
(MINIMUM �'EE $40.4U) Total = $ �� �'
THIS IS AN APPLICATION FOR A PGKT9IT-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 only a tion for a �i�-a�work is not to start without a permit; that the work will be in accordance with the
approved plan in e case of all wo res eview and approval of plans.
SIGNATURE OF A�N F-----� ' v � PRINT NAME DtG��+� }a'i� %'l17'ATE �—/^� Z
APPROVAL INSPECTORS SIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977