P - 46280Building MECHANICAL Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY D��'�� �`� �' ���
EFFECTIVE 1-1-2011
DATE CJ e�!/ l� YOUR E-MAIL�DDRESS �M�v'���'/�!f/�'"7 �C�/�'1G�S%• NL%%
SITE ADDRESS � )� � C�`� P�-�. (�.�
THIS APPLICANT IS: �QWNER OCONTRACTOR
PROPERTY
OWNER!
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
NAME: d� � YtK�/L-L�f �
ADDRESS: f /6 , �� ��- � CITY ��D ��'I STATB�'��%ZIPS�� y
PHONE: 7i� ' S7/ 87 i%�
COMPANY NAME: /
CONTACT PERSON:
STATE LICENSE # ,
ADDRESS: r�
PHONE �I63 � ,
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�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK H✓�L --
❑ 1'OWNHOUSE
$�ALTERATION/REMODEL
� SdPP�y
FEES ARE BASED ON SI0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (IIYDICATE TpTAL IYUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SiZE/BTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZElBTU
AIC $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $ I S FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOtLER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $14.00 GAS DRYER $10.00 ^POOL HEATER $35.00
�C DUCT WORK $10.00 _ _GAS PIPING $10.00 _VENTI LATOR $15.00
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 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 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 al ork �h�equires review and approval of plans.
` .ID �( �� �l��� S f /
SIGNATURE OF APPLICANT PRINT NAME DAT6 �/�/ t�
TURE
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977