P - 48222Building
Inspections
763-572-3604
763-502-4977 FAX
DATE f �+� �
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
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TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-I-2011
YOUR E-MAIL ADDRESS
O OWNER �'IC,UNTRACTOR
NAME: �
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PHONE: 7�0 � "S'iI � ��i 7i 1%
Pernut No.:
Received By: r��
Date �_ '� '� `� �
STATE ZIP
CONTRACTOR � •�'�•�•• r "` r �Y�-�� � �''`"� ���V4VVi6`7� LIr4�
COMPANY NAME:
SUBMITACOPYOF CONTACTPERSON: ������nrn
YOURSTATE STATELICENSE# ?_7(Ifl FQTRVI����jE AI
LICENSE WTI'H �D�ss: ROSEVILLE, MN 551� sTa� z�
APPLICATION pHONE 65�3.2561
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TYPE OF WORK:
H SINGLE FAMII.Y Q TWO FAMII.Y
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❑ TOWNHOUSE
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FEES ARE BASID ON $IQ00 PER FIXTURE, EXCEPT WHERE NOT'ID. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BII.OVIry
PROVIDE HEAT LOSS CALC'S PER MANUA,I� J 20 RAE HAND�OOK.
Equipm�t Installed MEG: J"F �i�iL�•° MODII.: �/0� 30 -- Sp SI7.FJBTU ���Ot�%i�.
MFG:
1��:�7�)�I IA
MFG: MODII.:
A1C 525.(�Y �FI PLACE (GAS) 515.00
AII2 TO AIR EXCHANGEER S15 FIItEPLACE (WQOD) 535.00
BOII,ER 535.00 FURNACE 535.00
Cf�vIIQEY LINER 510.00 GAS DRYER S10.W
DUCT WORK 510.00 �/C',AS PIPiNG 510.00
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tnb�r �►ffuctures ('3a $35.00 x �35:00 = $ :
Gte �rc�h�rge � $ 5.E)Q
�TN1MtiM FEE $40.U0) Total = $ �B, �%
SIZF/BTU
SIZFJBN
GAS RANGFJOVEN EIO.BtT
NEW GAS GRILI. 510.(�
GAS UAIIT HTR 510.00
POOL HEATER 535.00
VENTII.ATOR S15.OQ
THIS IS AN APPLICATION FOR A PERMIT-NOT V ALID UNTII. PROCESSED
I hereby apply for a building permit and I acknowledge that the informafion 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 w�o �is not to start without a permit; that the work will be in accordance with the
approved plan in the case of a11 work whic3�.Lequires r�v�5�` and approval of plans. _
SIGNA'PURE OF APPLICANT
APPROVAL INSPECTORS SIGNATURE
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City of Fridley
B ' 'ng Inspections Department
'� Universiiy Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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