P - 35465Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � I 1
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
1 ���" � G�-�7`�'"1j� (v-
❑ OWNER �ONTRACTOR
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NAME: ��(1U...J�CI i'"'j,�'�C ZC..CV:-l.,([� ��/'`�
ADDRESS: �_�� ��� C� \S�\ G✓1�A1' i� I'iC�I
PHONE: � q I pc — B I o� —���
COMPANY NAME: ��
CONTACTPERSON:
STATE LICENSE # L_1 J D�GS — V� EXP DATE
PHONE
FAMILY ❑ TWO FAMILY
❑ NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
FAX � I —'� � l -'
0 TOV�INHOUSE
❑ ALTERATION/REMODEL
Permit No �
Received By
�.C� ���
STA
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ATE�ZIP��
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (TNDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU L J 2006 ASHRAE HANDBOOK /�
EquipmentInstalled MFG: ��C�IY1C�-r'1 MODEL:I�IY��C�%O3P»X SIZE/BTU ��,��
MFG: �_iYXA,jr'� MODEL: �X I�-I �'T I SIZEBTU .�o�
MFG: MQDEL: SIZEBTU
1A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GR[LL $10.00
BOILER $35.00 �FURNACE $35.00 lGAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK SI0.00 _GAS PIPING $10.00 _VENTILATOR $15.00
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
eonformance 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 applicatio 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 wo 'ch requ' s eview and approval of plans.
SIGNATURE OF APPLICANT II PRINT NAME (J��W F � DATE �� t
APPROVAL INSPECTORS SiGNATURE / � /J.t,/�) TIATF // �
—� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977