P - 45674Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIALEY
763-502-497% FAX ErFECTfvE�-i-ZO�o
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DATE_- -- --
Sl"fE ADDRESS _
THIS APPLICANT [S:
PROPERTY
OWNER/
TEIYANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
l�
❑ OWNEK
NAME �
A DDRES S
PHONE �
CITY
. P1r11V�..1 0l nl�� ��'�v.
COMPANY NAM �
CONTACT PERSON�nvc+�s'n 1 ��1A1 G��
�
STATE L[CENSE #�a�� 7nfl���_ �XP DATE
ADDRESS: _ _.
SINGLE FAMILY
TXPE OF WORK: I� NEW
DETAILED DESCRIPTION OF WORK
CITY
FAX
❑ TWO FAMILY ❑ TOVJNHOUSE
EMENT Q ALTERATION/REMODEL
Permit No.:
Received By:� � YIJC
Da��' � �' �" `� � 2 � 1
STATE ZIP
STATE ZIP
FEES.4RE 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, /J (�/ �,� �,+`, / �
Equipmentlnstalled MFG: �Q,1'11/�Q�C MODEL: �7 �_ ri v�Gj���/ SIZE/BTU
MFG: IJ��U�� MODEL: � 17 �� l/ SIZE/BTU ______.�%—l�/r 1
' AIC $25.00
AIR TO AIR EXCI-IANGEER $15
BOILER $35.00
�CHIMNBY LITiER $10.00
�DUCT WORK $10.00
MFG: MODEL:
FIREPLACE (GAS) $15.00
�REPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYEft $]0.00
�GAS PIPING $]0.00
SIZE/BTU
GAS RANGE/OVEN $10.00
�NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
^POOL HEATER $35.00
VENTILATOR $ ] 5.00
THIS [S 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 wil( be in
conformance with the ordinances and codes of the City of"�ridley and with the Minnesota Construction Codes; that I understand this is
not a permit but 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 � or,k ich requires review and approval of plan
SIGNATURE dF APPLICANT "'" = .y 1 PRINT NAME �' �� �j� / `--�'' � DATE /� �� � �
_ . ., �
APPROVAL INSPECTORS 51GNA
_�' City of Fr�dley
�Building�Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977