P - 84321Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY -
763-502-4977 FAX EFFECTIVE 1-1-2012 -
DATE I l� / 2
SITE ADDRESS �
TH[S APPLICANT IS
OWNER
PROPERTY NAME:���, �
OWNER/ ADDRESS: +
TENANT pHONE:�UC� • ��� �
IL ADDRESS
CITY
Permit No.: G(x,���
Received By: �i�
Date �� �1 f'. T 2 d. ?��
-��L�'ll)P5l- Cc�vl�l
ATE' ��"'ZIP
CONTRACTOR COMPi
corrT� Four Seasons Air Specialists Inc
SUBMIT A COPY OF 4457 White Bear Parkway Suite B
YOUR STATE STATE E •
LICENSE W[TH ADDR� �ite Bear Lake MN 55110 _crl.Y STATE ZIP
APPLICATION (651) 426-5254
PHONE
PERMIT TYPE �NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW �REPLACEMENT
DETAILED DESCRIPTIQN OF WORK I( O Ni1.�S�
❑ ALTERATION/REMODEL
•�-
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CA]yC'S PER MANU L J 2006 AS RAE HANDBOOK. �y f' A �/�+_ n�. „��
Equipment Installed ,_jj � 4r� MFG: �(� MODEL:E��-t � 1� �l D\ ��PCSIZElBTU ��x, v -
--�.�,.
�%�1 MFG: IXVLi1 �!� MODEL: C I�'�' • �V SIZE/BTU Ol � �� Od
- J T
I EvC $2s.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
j 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 $10.00
POOL HEATER $35.00
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 a codes the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an appli tion a erm d w rk is not to start without a permit; that the work will be in accordance with the
approved plan in the case of l work whi s e iew and approval of pl s.
SIGNATURE OF APPUCANT PRINT NAME �w'�� "�'' DATE �' Z;'- � L
AL INSPECTORS SIGNA
DA
► City of Fridley
Building Inspections Department
1 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977