P - 48170Building MECHANICAL Permit No.;��,i rG-���1 b�.
Inspections RESIDENTIAL APPLICATION Received By: ��1'�
763-572-3604 ec�' ^"
763-502-4977 FAX CITY OF FRIDLEY �� ��
EFFECTTVE 1-1-2012
DATE r^ ��— z �� 2— YOUR E-MAIL ADDRESS
SITE ADDRESS � S 7 7 LF l D E� W� Y
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
NAME: S'I-� V�/� S C�'�'-
AnnxESS: 7� y y A-1 �r� �w r9-y
PHONE: �P i 2-2� !^ S'� S�, �
COMPANY NAME:_
CONTACT PERSON:
STATE LICENSE #_
EXP DATE
F/2 %� ( r i sTA� w� Nz� SSY3
ADDRESS: CTfY STATE ZIP
PHONE FAX
PERMIT TYPE ��GLE F.41vnLY ❑ TV✓O FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT �1LTERATION/REMODEL
DETAILED DESCRIPTION OF WORK %�t ,����r �'✓oo d'_ F� �-F �%[ r �'
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/BT[J
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEJBTU
_A/C $25.00 REPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL 510.00
_BOILER 535.00 _FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $]0.00 GAS DRYER $10.00 POOL HEATER 535.00
DUCT WORK $10.00 GAS PIPING $10.00 _VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
,' �I-
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 applicatiog�or a permy�' d work is not to start without a permit; that the work will be in accordance with the
appmved plan in the case of all w� which r res review and approval of plans.
SIGNATURE OF APPLICANT
APPROV
c a�T Dn� 1-17— 2��2'
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977