P - 35074Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE_ "r �l�=�
SITE ADDRESS �,
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
YOUR E-MA.IL ADDRESS �( I�I V� �
. ��
❑ OWNER QCONTRA
NAME: (.
ADDRESS: - � ��)
PHO�: ��a - �� � ��
COMPANY NAME:� �1
CONTACT PERSON; __!� f���
STATE LICENSE #_ �
ADDRESS: � ��! /iLLLI'.S�TO
PHONE � 7- ��� °� �t+Z-�
SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: I � ��'�'
DETAILED DESCRIPTION OF WORK
F.� �/�3-�i����1��
❑ TOWNHOUSE
O ALTERATION/12EMODEL
w (��-. f
Permit No.: � 1 �`< 3"'
Received By: �
Date�'�: � U L �
14"G �-C`OYY�
STATEm�"ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUM$ER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUA J 2006 ASHRAE HANDBOOK �1L/� y� �� U 5��� � ��G✓
Equipmentlnstalled MFG: /�l� � � MODEL: 7°�'UV
MFG: _ MODEL: SIZEBTU
� � MFG: MODEL: SIZEBTU
`� A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIl2 EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GR1LL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 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
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 buf only an application 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 all rk Yvhi r quires review and approval of plan .
SIGNATURE OF APPLICANT 4��� PRINT NAME /1.' �! �I� � r� DATE ���� -� I I
AL
�TE �� L !
City of Fridley
B ' ing Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977