P - 35804Building MECHANICAL permit No.: 26(1'60 �
Inspections RESIDENTIAL APPLICATION Received By:�Q��"�----
763-572-3604 CITY OF FRIDLEY C�t��� ��-���
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS _ )� �,�I� �_�,� � •
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY N�:
OWNER/ ,�DRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR co�arrY N�: Y 1'�lOrl l �-
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSEWITH p�DRESS: � p a, 1f� CITY LQ�.+�, ' �.�'"� STATE�ZIP�'/IIU
APPLICATION pHONE "ID�l FAX ' — I �
PERNIIT TYPE �S�GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � �W '�PLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �
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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: (` Yl-C�Y MODEL: �uV ����� SIZEBTU __�_
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 _FIREPLACE (GAS) $15.00 _CiAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIT2EPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
_BOILBR $35.00 �FURNACE $35.00 _GAS UNIT HTR $10.00
CHIlvINEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
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umbe o res� '$1� 0 ` 3 0 � � � � ,� �
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=� ut�ber of'f'�ctures @ $25 OQ � �x�25 00 ,�$� � , :� > � � � � � � ��
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4 { i�` � � s' � k �� ��5z� E� � � �v-" ji
', Number of fixtures $35 00, x;$35 00 = $ .;���� ��� 4 � � � '���� ��' �'� `'��� �
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! State Surcharge 5 OQ
NIMUIVI FEE $40.00 Tota1= �
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THIS IV�`PT'LICATION 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 work, hich requires review and approval of plans. �/g�3
SIGNATURE OF APPLICAN PRINT NAME�� (�1,1;4i'lif � DATE O(!S
APPROVAL INSPECTORS SIGNATURE DATE
=�;���;�PLEASE NOTE: SEPA�ZA'T�~�E�ZMI`TS;ARE RE ,i1IRED;;FOR'BIJILDING. EL�C'I'RICAI. AND`1VIECHANIGAL��ORK���-`�;
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977