P - 36702Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � I ' O
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
❑ OWNER
CONTRACTOR � COMPANY
YOUR E-MAIL ADDRESS
CITY
Permit No.:
Received By:_�
D���'��a`"'� � �
A'
SUBMIT A COPY OF CONTACT PERSON: FI+OYD JOSWICK
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ,�Dt�ss:7221 University AVe. N. E. CITY Fr1CZ�.eV STATEMN ZIP 55432
APPLICATION pHONE 763-572-0459 F,4x763-572-0164 �
PERMIT TYP'E ' �SINGLE FAMILY � O TWO FAMILY
TYPE OF WORK: � ��'�' ��P�CEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON S10.011 PER FIXTURE, EXCEPT WHERE 1VOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU 006 SHRAE HANDBOOK
Equipment Installed MFG: MODEL: � SIZEBTU
MFG: ��(+�� MODEL: ���j� SIZEBTU
MFG: MODEL: SiZE/BTU
,�CA/C 525.00 _FIREPLACE (GAS) 515.00 _GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER 535.00 �FURNACE $35.00 _GAS UNIT HTR $]0.00
CHIMNEY LINER S10.00 GAS DRYER $10.00 POOL IiEATER 535.00
^DUCT WORK S10.00 _GAS PIPING $10.00 _ VENTILATOR $15.00
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 ordin ces and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a penmit but only an ap ication 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 o 11 work wl� rec�}iy�s review and approval of plansj AA ./1
SIGNATURE OF APPLICANT
PRINT
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
DATE� ' '