P - 45676Building � MECHANICAL ' Permit No.:
Inspections RESIDENTIAL APPLICATION Re�i i��
763-572-3604 �1�� . �' ��� ��� �
CITY OF FRIDLEY Date Rec'd: �
763-502-4977 FAX EFFECTIVE 1-]-2011
DATE � YOUR E-MAIL DDRESS
siTEa.���ss �� �1 � _ �Ja�CA..1��� (�n '� :�.5`a
7'HIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NqME: M -2;
T� NAN�T ADDRESS: �':� � t � `�, � Cs1.�t G�.Y� C[�T�1'� '��`"Y1 � � � 1 STAT�il�ZIP �S ��
PHOAIE:��ir���('� -- [) I��
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
COMPANY NAME: .
CONTACTPERSON.
STATE LICENSE #� EXP DATE
ADDRESS: ��" \, � � `Y�( ),li.i �C' i�. CiTY .�__�(��,� STATE�i�IP
PHONE�����' �`�+n FAX
-7�-
TYPE OF WORK: { a NEw
FAMILY ❑ TWO FAMILY
DETAILED DESCRIPTION OF W ORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE SASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANIIAL 406 A HRAE HANDBOOK. ,( /.--��,,r�
Equipment Installed MFG: MODEL. 1`��j�� Ctti�A�-�SIZE/BTU
MFG:
MODEL:
MFG: MODEL:
�A/C $25.00 FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $ I S �FIREPLACE (WOOD) $35.00
_BOILER $35.00 �FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
VDUCT WORK $10.00 GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
_GAS RANGElOVEN $10.00
_NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
lPOOL HEATER $35.00
VENTI LATOR $ I 5.00
THIS IS AN APPLICATtON FOR A PERMIT-NOT VAL(D UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wiil be in
conformance with the ordinanc codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an ap tcati 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 cas of al ork which reqt�res revie� and approval of plans.
SIGNATURE OF APPLIC � NT PRINT NAME � � DATE
AL INSPECT�CS SIGNA
' City of Fridley -
Bu' ding Inspections Department
niversity Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977