P - 35064Building MECHANICAL Permit No.: __
Inspections RESIDENTIAL APPLICATION Received By:��
763-572-3604 CITY OF FRIDLEY D�'��-�� t
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE ��� I_�l� YOURE-MAILADDRESS �r(V�O�,V1Q, _ eSU'1LLO�.001M
SITE ADDRESS �O �•Q.ir� l.t,r(�'C�
THIS APPLICANT IS: O OWNER �CONTRACTOR
PROPERTY NAME:
OWNER/ ADDRESS: CTI'Y STATE ZIP
TENANT
FHONE:
CONTRACTOR co�.a,rrY NnME: i
SUBMIT A COPY OF CONTACT PERSON: �Y ,;/1 �Y1U- l�I GX ✓'�s
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH �DRESS: CITY STATE�ZIP S�f3 �
APPLICATION pHONE (p FAX � �0 � � � S �{R 3
PERMIT TYPE �INGLE FAMILY ❑ TWO FANIILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW QQjREPLACEMENT ❑ ALTER4TION/REMODEL
i .�
DETAILED DESCRIPTION OF WORK � �t- C d-
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANU J 2006 AS E HANDBOOK v��1,��,
Equip�ntInsffilled MFG: `�����} MODEL: C� YYIY tivl(/v�io�-� SIZE/BN �'r'��o ����
MFG: C7-f- t-M� �"� MODEL: � i'� ��X C�Lli"� STZEBTU
MFG: MODEL: SIZFJBTU
�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 �+ FiJRNACE $35.00 _GAS iJNIT H'TR $10.00
_Ci�IIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
Number af fixtures @ $10.00 x $10.00 =$
Number of fixtures @ $15.00 x $15.00 = $
Number of fixtures @ $25.00 ` x $25.00 = $ �J b�
Number of fixtures Q $35.00 � x $35.00 = $ � • �
State Swcharge = $ 5.00
MINIMUM FEE $40.00 Total = $ • �
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 only an application for a rmit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the c ' s review and approval of plans.
,....
SIGNATURE OF APPLICAN PRINT NAME���. ��� � DATE �
APPROVAL INSPECTORS SIGNATURE DATE
PLEASE NOTE: SEPARATE PERMITS ARE RE UIRED FOR BUILDING, ELECTWCAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977