P - 45292Building MECHANICAL Permit N`. - C�
Inspections RESIDENTIAL APPLICATION Received By:'ln '
763-572-3604 CITY OF FRIDLEY DR����-�-�-�-����
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �"� �� Z� t2 YOUR E-MAIL ADDRESS
SITE ADDRESS C9 Z7S � R1 V��
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY NAME: v v Gt CI.� ��1Q.�1
OWNER/ �DRESS: ��LR C�'}� �.Q,�1 L CITY L� �Lp_ STAT�iwiZIP��
TENANT
PHONE: �� � � �� ' � 1�
CONTRACTOR C01�rn.ANY NAME: �1 ilrle S �. � vtv� � � C17�"1 n
SUBMIT A COPY OF CONTACT PERSON: M�L.IC. S � L w b
YOUR STATE STATE LICENSE # O� � da i EXP DATE �e� 31 ��
LICENSE WITH ,e,DDRESS:�� W•3'� �+-- CITY �h�IG'�Q—s�c.. STATE�`'1 ZIP �� /
APPLICATION pHONEQ� a��J �iy`��-/ FAX �JS � U4S" GlyO �
PERMIT TYPE �R SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �Q REPLACEMENT � ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �Q.Q IAl..e �UY1�1GC�
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: SIZEBTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
_A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 _FURNACE $35.00 �GAS UNIT HTR $10.00
CHIMNEY 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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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 and code f the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicatio or a pe it and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all w k w" h quires rg�+iew and approval of ans.
SIGNATURE OF APPLICANT� '��f � PRINT NAME �� ��bw (�_DATE � � / � ��
APPROVAL INSPECTORS SIGNATURE ` ' (,G DATE
City of Fridley
uilding Insaections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977