P - 35486Building MECHAl'+TICAL
Inspections ��II}��TIAL APPLICATIUN
763-572-3d04 CITY' OF FRID�EY
763-502-4977 FAX Cr�LCTt��c a-�-zoi c
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SLTE ADURFSS ��
7T{IS APPLICANT IS:
PROPERTY
OWNERJ
T�NANT
COIVTRACTOR
SUBh7(T A COPY �f
YOURSTATE
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APPLICATIOT
PERMIT TYPE
(J ` J" ' ' YOURE-MA1L A�DRESS
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� QW[CER }�ON'CR.�CTOR
NAME: f�Q a,� aiJ� t�
ADDRESS:_�t'� „��/lii �/!�/� �,�
PHOVE: �I�Z '�' S�� ��%'S� r
Permit
Reeeived By:.
ri..... n..,.�a.
�it.�I�G� STAZ'�fLIPt��,
COMPANY IVAM}:: � / r � � %9
CONTACT PE[tSON: /
SS�L[CGNSL# — Q�.�,/ EXPDATE. '���3�-�/%
ADARESS:_�iI I"���L�% CI'I'Y �.�i�°v` STAT�ZIIj55�9
PHO�IE ��' SG..� �/2% NA7i 7f.� � S,i�s..� .� %�
FAMiL) ❑'E"WOFAM[LY
TYPE OF WORK: I O xEw �REPL.ACEMENT
C�'ETAILED DESCRLATI�N OF WORK
❑ TOWNMOUSE
❑ ALTERATION/REMODEL
FEES A[tE BASED ON SI0.00 PER F7XTURE, EXCCPT WHERC NOT�D. FfXT[fR£S: (iPIDICATE TOTAL NI;MBER OF EACH BELOVY)
PROViDE HE.4T LOSS CALC'S PER MAIYIJAI. J 2006 ASHIiAE HANDBOOK
�quipment2nstalled Mr•c: ��i/,94�OA9z y ntoaEr_: ���'1.�'��� s�z��v �O�ip
MFG: MODEL: StZE1BTU
MFG: MODEL: SIZEJBTU
A/C $25A0 FiR6PLACE (GAS) $ I5.00 _GAS RANGFIUVEN S1U.00
A1R T� AIR EXCfiANGEER $15 F(RfiPLACL- (WOOD) 535.04 _„NEW GAS GRILX. Sl C.QO
_BOILER 535.00 �fURNACE 535.00 GAS UNl'f H7R S10.00
_CHIMNEY L1NER �10.00 _GAS DRYER 370.00 Pt70L HEA7ER S3S.Q�
DUCT WORK $I O,OQ GAS PIi'iNG 510.00 �VENTILATOR S15.00
Number of fixtures @$ I0.00 x$ I O.OU
_ � �`� M
Nwnber oP fixtures Qa S I 5.4t1 x$ l$.00 =$
�
Number of fixdues @ �25.40 x $ti.00 = $
Number of fixbures @ $35.00 � x $35.00 = $ ,,,�'�a�
State Surchazge =
FEE 540.001 Total =
a _ s.00
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TH[S LS AN APPLICATIOI� FORA PE2lvi1T-NOT VAI.ID UN'FIL PItO��SS��'��-"^"'��
I hereby apply for a building permit and I acknowledge tl�at the information above is eomplete and accurate; that the work wi in
conformance with the ordinances and oodes afthe City of Fridley and with the Minnesota Coasfruction Codes; that I understand this is
not a permit but only an application for ermit and work is not to start without a permit; that the work wil� be in accor�dance with the
approved plan in the case of�ork which „ uires ew an pproval of plans. ,
SIGNATURE OF
SE NOTE:
DA
TE PB RE UIRED FOR SUILDING, ELECTRIIGAL A;
City of Fridley
uiMding Inspeetions Department
6431 Universiry Avenue NE, Fridley�, MN 55432
763-572-3604 FAX: 763-502-4977
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