P - 35477Building
Inspections
763-572-3604
763-502-4977 F.
DATE�
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
l (�
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2010
❑ OWNER
YOUR
NAME: � �'C C U �'
ADD�sS:J� �?3�i L.�v���
PHONE: � � I ' G i � �` °
COMPANY NAME: CP�C�' L
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE #
LICENSE WITH ADDRESS:��
APPLICATION pHONE �Tfn��" i
PERMIT TYPE
TYPE OF WORK: I� NEW
FAMILY
�(�(k) FAX
❑ TWO FAMILY
Permit No.
Received By•
D�����ov i 201
ATE�%r=LIP �'u5 j.� �
EXP DATE ���� �
�� CITY L'eT STATEi� Y�IP SS %
❑ TOWNHOUSE
'�'1�EPLACEMENT ❑ ALTERATION/REMODEL
�,.
DETAILED DESCRIPTION OF WORK
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: MODEL: SIZEBTU
MFG: I`''► �.C.L� lY� MODEL: ���) Ic�D" SIZEBTU �(�U C� _
_A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00 —
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
�FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $]0.00
POOL HEATER $35.00
VENTILATOR $15.00
— � ;
�
State Surcharge = $ „�� ��
(MINIMUM FEE' $35.SU}.. Tcrtal= $
�
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 co��s of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for� 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 re ' es review and approval of plans.
I,., (,� , ''t,�./
SIGNATURE OF APPLICANT . NT NAME I���I� �{.f 1✓�C� C i`x'�TE � I��
APPROVAL INSPECTORS
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977