P - 48136Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE �-�-zoi i
DATE .(_K (_,
SITE ADDRESS c�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
Permit No.:
Received By: I�r
d�� ,� i
,
YOURE-MAILADDRESS /�I'f"C� Cr �C%�c�,c� 'h�c r'�'•^� . �'an--�
ADDaESS: >�y��_,�;; m� L,¢�c[2 b/�P cr�r,r w��"� 6 r�✓' ,G9� STATE�N ZIP ���
PHONE: CO pc -� �
COMPANY NAME: �Q /� .�.p / ��7 � /gi%�
CONTACT PERSON: � i/ ao-
STATE LICENSE # l0 EXP DATE
ADDRESS: S I TO �r 1�'I �i �� /V•� CiTY 'rt G�. '�/�(. STATF��ZIP SSy3�
PHONE ��D 3^ %��-OSS`�S� FAX _`%� 3' %Bd� .� Z
SINGLE FAMILY ❑ TWO FAMILY
�REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOIC.
Fquipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZElBTU
_A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $ I 5 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
_CHIMNEY L[NER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 _GAS PIPING $10 00 VENTILATOR �15.00
THIS IS AN APPLICATtON 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 rmit and wor is not to start without a permit; that the ork will b in accordance with the
approved plan in th of all w• c whi quir w and approval of lans.
SIGNATURE OF APPLICANT PRINT NAME 9+1 � DATE �� ����f�
APPROVAL INSPECTORS SIGNATURE n e�r�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977