P - 45282Bttilding
Inspections
763-5'72-3G44
763-502-4977 FAX
MECHANIC.A,L
RESID�NTIAL APPLICATYON
C�TY OF FRIDLE�'
EFFECTEVE l-1-2011
,�d��"'%
Permit T��o.:
Receive�
Date Rec'
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DATE— _� � p�/ �1 �1 /��
YOUR E-n1A1L ADDRESS _ L.B � O`� d I �p C%'M/�2L. GU/t%
s�TS nDt�RCSS I S g� /�� '►`A2 �. 2 v,�, f 2"'O[..�
THIS APPLiCANT 1S: �jj,QiliTTBR �JCQNTRAC70R ^^ � �
PROPERTY i+lAME: S�T�(,� N_,�- ���
OR�I�tEIi/ ADDRESS: 1� ¢��J E3K .x'H.2(,?'.�G.�� /zl�
1'EnANT Ci�' F-� �OC_..�E�' STATE�ZIp gS�32
Pi-ION�: F>Ic`�r�0 •��j" �'% �
SUBMIT A COPY OF
YOURSTAT6
LICEA�SE tViTH
APPLICATION
COMPAidY tIAME:
CQNTACTPERSON:
STATE LICENSE k
EXP DATE
ADDRESS: CITY STATE ZIp
PHONE FAX �
P�I2iVIIT TYPE '�S�NGLE FAMiLY Q'tiVO FA1�4tLY
TYP� QF «'OT2Tt: Q �E��' � ftEPLnCEh1Er��r
DETAILED DESCRIPTIQN OF WORK
_LV'A �(i 2� � �o c7 i G
O TOtYNFtOUSE
�t'ERATtON/REMQDEL
3c.�`s � a �r
' b,�J-�' 1�rv :
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FEES ARE BASED O� S10.00 PER FIaTUR$, EXCEPT �yFiERE nOTBD. FIXTURFS: (Il�'D�CATE TOTAL NU1116ER OF EACH BELOR')
PROVIDE HEAT LOSS CALC'S PER AfANUAL J 2006 ASHRAE HA�DBOOK.
Equiprnent InstaHed A4FG: MODEL: SI2E/BTU
MFG: MODEL:
S12FJBTU
iviFG: MODEL: SiZE/BTU
_A/C $25.00 FIREPLACE (GAS} � F 5.00 GAS RANGFJaVEN £ 10.00
AtR TO AIR EXCHAI�IGEER Sl S �FIItEpLACE (\VOOD) $35.00 �NEW GAS GRFLL 510.00
BOILER S35.d0 �FURNACE $35.00 GAS UNIT NTR S 10.00
`CHIMNSY LINER 510.00 "GAS DRYER Sl0.00 'pOOL H�AT6R $35.00
DUCT WORK $10.00 �GAS PiPING � 10 00 ^V ENTILATOR $ I S.QO
�rtX� c rsr i�,. r r. n:a �^'�°'�"��n�r: �ni ■ _
__. .. __.._ _._...,....._..
THiS IS AN APPL(CA710A! F4R A PERM)T-NOT VA4ID UiV7'!L PROCESSED
I hereby apply for a building permit and I ackno�i�ledge that the infortnation above is complete and accurate; ti�at the work �vill be in
conformance �vith the ordinances and codes af the City of Fridley and ���ith the Minnesota Construetion Codes; that I understand ihis is
nof a permif but only an apptication for a ern�it and tivork is not to start without a pennit; ihat the �vork �viil be in accordance �vith the
approved ptan in ttte cese of ai! wark �vlaieh r t►ire rev;ew and appraval af plans,
SIGI�IATURE OF APPLICANT �� 4i�..�.w/ PRINT 1dAki6 S`IF Uf:� /t/.�,� �/� �DATE '- t�f l
.��n...,., .�,���_....�_----- - i .,, /1 � „ . , T
�w�� City of Fridley .
Building Inspections Department
6431 Urriversity Avenue NE, Fridley, MN 55432
763-572-36�4 FAX: 763-502-4477
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