P - 48574Building
Inspections
763-572-3604
763-502-4977 FAX
DATE !Y1 Ar c(.t,,,
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
MECHANICAL Pennit rto.: L.U�I
RESIDENTIAL APPLICATION Received By=�,,�
CITY OF FRIDLEY Date xec'ct: `
EFFECTTVE 1-1-2012
�� Z O/ Z YOUR E-MAIL ADDRESS � A' e- � C%� O N' r) e�t j i'� . COM
f'�e_nn2T J7�_�_�. �t .
❑ OWNER ,$(CONTRACTOR
ADDRESS: 7 Cp � � e � n e.TT � r N. f cr� P-�'�'al l-r
PHONE:_�G� 3 •... .57�'- � % l�G� �
COMPANYNAME: /TC / 1 oh% • a% in �/'�i�
CONTACT PERSON: �.� --i �n V I w n__
TENI�LIP�L
STATE LICENSE # �5 0 �f `Z % �o � EXP DATE
ADDRESS: � / y0 �(� � � % , iV. � . CTTY /�--Y'i••P/,r � STATE ��ZIP,
PHONE %(0 3 �- 7 8 � ` � S �/S� FAX �� 3 � % �o � %,3 ��
PERMTT TYPE �SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEW �REPLACEMENT
DETAILED DESCRIPTTON OF WORK
❑ rowrrxousE
❑ ALTERAI'ION/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 ASEIRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZE/BN
MFG: A%��1'�� MODEL: STZEBTU �� �
MFG: J�%ii�/�- MODEL: SIZEBTU L��
iCA/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
—AIR TO AIIt EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 �FURNACE $35.00 _GAS UNIT HTR S ] 0.00
CHIIvIIQEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK 510.00 GAS PIPING $10.00 _VENTILATOR $I5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 ali� ov�rk which requires r ew d approval of plans.
SIGNATURE OF APP -�� PRINT NAME3 Io f� v� V/A � DATE / ���
APPROVAL
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977