P - 48175�ili ding MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE / "� `1 " I i
SITE ADDRESS .3 �d
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
YOUR E-MAIL ADDRESS /� a N
�
❑ OWNER �dC�ONTRACTOR
ADDRESS: � S� ,, �s�� Lil� %Y� CITY
PHONE: �� ��'Ti %I " �`'+�y�
Pertnit No.:
Received By: � �
Date Rec'd: � �3 � �
R�(''11 J �� � � ► �
CONTRACTOR -- -- - - - - -- . . _ . . _ . _ _. .. ... _......�.,, .,....
COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON: LiC (�C,QS� �n�n
YOUR STATE STATE LICENSE # 2700 FAIRVIEIMF.�iV�BE N
LICENSE WITH ADD�ss: R SEVILLE, MN S�I1�Ty STATE ZIP
APPLICATION pHONE
PERNIIT TYPE
TYPE OF WORK:
C�'S�INGLE FAMILY ❑ TWO FAMILY
�vEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
J � A
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVh
PROVIDE HEAT LOSS CALC'S PER MANU J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: �,l��iut- _� MODEL: C� F L�1l� �D-L SIZEBTU �OLk}c+
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 �ACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 _FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
DUCT WORK $10.00 _GAS PIPING $10.00
SIZFJBTU
SIZFJBTU
_GAS RANGF/OVEN $10.00
NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
S"s'y3 L-
� THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 Construcrion Codes; that I understand this is
not a permit but only an application for a permit d work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work which req es review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME � li��"�� k� � DATE C-�`—� �
APPROVALINSPECTORSSIGNATURE � DATE I
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-36U4 FAX: 763-502-4977