P - 48476Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ' !i
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
rxorrE:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
❑ OWNER
YAUR �MAIL
COMPANY NAME: fI/,a f�+l �"+ �t.�fsLa �lilt.� .�/—�e
CONTACT PERSON: _��,�L�y{ 1�C � N
STATE LICENSE # EXP DATE _
ADDRESS: CITY,
PHONE
❑ SINGLE FAMILY ❑ TWO FAMILY
❑ NEW � REPLACEMENT
DETAILED DESCRIPTION OF WORK
FAX
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
Permit No.:
Received By�/�'�r
Date R�� F � � 2 �
STATE ZIP
TE ZIP,
FEES ARE 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
Equipment Installed MFG: MODEL: SIZFJBN �
MFG: MODEL: SIZE/BN ,
MFG: MODEL: SIZE/BN �,�
_A/C 525.00 _FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRI1,L $10.00
_BOILER $35.00 _FURNACE 535.00 _GAS UNTf HTR $10.00
Y LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
UCT WORK $10.00 GAS PIPING $10.00 �TILATOR $]5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
T 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 applic 'on for a pe and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of rk whic eq ' es review and approval of plans.
SIGNATURE OF APPLICANT PRiNT NAMF.y�N ���s n� DATE �^� `�"o�%��
APPROVAL INSPECTORS S NATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
���
T