P - 36716Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE ]-1-2011
DATE / %/' o
SITE ADDRESS �
TH1S APPLICANTIS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
DETAILED
� YOUR E-MAIL ADDRESS ��j'Z`s�
Z �G f C/'C/7�
❑ OWNER �pNTRACTOR
NAME: p C° � � �
ADDRESS: �S3S C9a%��/7� CITY�l��
PHONE:� '^ ��l //YST_
Permit No.:��1� —(a9>i��
Received By: �_ � �' �
D��`������ ��
ATF/1%(%ZIP
COMPANY NAME:G�1r G' � �' r
CONTACTPERSON:�i/+?i�/�- , �l�c� v
STATE L[CENSE # EXP DATE _
ADDRESS:�b %�j D p2 �� �c.G� 4C� CITYl�"J��r /l'G- STAT�•l/ZIP
PHONE � Z�' ��3 :20%� FAX �. Z!i'7C3'� 2�O d I
FAMILY ❑ TWO FAMILY
�IEW �,'REPLACEMENT
ONOFWORK ����
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: {INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: �QGn�-- MODEL: �� SIZE/BTU � t%
MFG: MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
~AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 ,�'FURNACE $35.00
�fHIMNEY LINEEt $10.00 GAS DRYER $10.00
�DiJCT WORiC $10.00 �'AS PIPING $10.00
SIZE/BTU
S1ZE/BTU
_GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
_POOL HEATER $35.00
_VENTILATOR $15.00
THIS IS AN APPL[CATION 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 wifl be in
conformance with the ordinahces 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 ptan in the case of all work which require,� r view and approval of plans.
SIGNATURE OF APPLICAN ��i�� !'-z„ .�- PRINT NAMF�„!/�/+q, j?L ;�vv�0' DATE �''���2�[ I
AL
TURE
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977