P - 35066� -��H 7
Building MECHANICAL Permit No:� I U UoRC�`�
Inspections RESIDENTIAL APPLICATION Recei�ea By:
763-572-3604 CITY OF FRIDLEY Da��'
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS _ 7� Y� � Y -�j�(,fr S� . N�
THIS APPLICANT IS: ❑ OWNER C�?f;ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
NAME: (Jt ✓IdPJ� + K t G/�tGtYc� U 1 �✓ W
ADDRESS: 7���% �}(�' �F-G1t.�Y �. N� CITY,
PHONE: �i (�� '% g � a
COMPANY NAME:�
CONTACT PERSON:
�
A7'E/' �IP
STATE LICENSE # EXP DATE +I
ADDRESS: �78 �lCL �LlItCI /�//�/ N CITY„� Y��/jI�G17 TATE�►�LIP,
PHONE i(� ?i � S�? (.i � b(e (f 7 FAX
SINGLE FAMiLY ❑ TWO FAMILY
❑ NEW j�ZEPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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: (� � Iih�G MODEL• SIZE/BTU %d � Q�d
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
AtR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 �FURNACE $35.00
CHIMNEY LINER $] 0.00 GAS DRYER $10.00
_DUCT WORK $]0.00 GAS PIPING $10.00
SIZE/B7U
SIZE/BTU
GAS RANGEIOVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
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 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 w rk which requires review and approval of plans.
SIGNANRE OF APPLICANT /% �"""� PRINT NAME /�`L1 /''`'��K DATE �I ��°
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Frid(ey, MN 55432
763-572-3604 FAX: 763-502-4977