P - 48047Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-20] 1
DATE i'/�- j C
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
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SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
O OWNER
YOUR E-MAIL ADDRESS ,/q
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�CONTRACTOR
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ADDRESS: � �S / �/t� S/'- �L- YY � CITY
PHONE: �G% �—= � � ,� ^- %� c��
Permit No.:
Received By: J V' i�'
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ATEM��ZIP
COMPANY NAME: C' / r �%(J (-'�X � j , :'� • ? i�
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CONTACT PERSON: A i.. - '"
STATE LICENSE # �O �vt C� S EXP DATE
ADDRESS: ,9 I �%Ci c%�i i�✓T $'"T , /j/, �t' CITY_��: �l %`�' ry STATE��ZIP �Sy,�
PHONE �%� j ' 7 �—� ._L;' � �' � FAX �� 3 7 S�=' .. � .Z Z
PERMIT TYPE I�NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW 1�1'REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �c:` �"� �� �-c,� �,�,l�v✓}� ,�y
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/B?U
A/C $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
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 $]0.00 GAS PIPING $10.00 VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D UNTIL PROCESSED
I hereby app(y 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 theCase of all worl�-�v}rie�h equires zGie nd approval of plans.
SIGNATURE OF APPLICANT � , '�/ .�� PRINT NAME_� '�i1Y� %`# (q N p� �,qTg /�•— �
o v r� • �c�i %
AL INSPECTORS
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977