P - 37229Building
Inspections
763-572-3604
763-502-49�7 F
DATE ( ( ( `
SITE �DRESS _
THIS :�PPLIC.4NT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIV'E 2-19-09
E-NiAII. ADDRESS
❑ O«NER
� � �i%�� �i,C%
.. � �� �� ,r� . ��i�
COnIP.�.Nl' N.�fE. .�.a�wa�.. i ��.�.u��y .... .�. �..,............ .
CONTACT PERSON: Ym�
STATE LICENSE # F � 7�R74_7� DATE
ADDRESS:
PHONE
F�•IILI' ❑ T�l'O F.�III,1"
❑ NE�I' �EPLACEr-fENT
DETAILED DESCRIPTION OF WORK
CITl'
FAX
❑ TO�NHOUSE
❑ AL"i'LRATIONfRSh40DEL
Permit No. - �, - —� �'� (
Recei��ed B��: ��� -
D���`�'��lV �
'tE ZIP
FEES ARE BASED ON $10.00 PER FIXTIJRE, EXCEPT WHERE NOTED. FIXTURES: {INDICATE TOTAL NUMBII2 OF EACH BELOVf�
Equ"spment lnstalled MFG: MODEL: SIZF/BTU
MF �/✓1'^� MODEL: CS SIZFJBTU )
A/C 525.00
AIIt TO AIR EXCEIANGEER $15
_BOII,ER 535.00
_CITI�fNNEY LINER $10.00
DUCT WORK $10.00
MFG: MODEL:
_FIREPLACE (GAS) $15.00
FTREPLACE (WOOD) $3S_00
/�FURNACE $35.Q0
GAS DRYER $10.00
GAS PIPING $10_00
SiZE/BTU
_GAS RANGElOVEN 510.00
NEW GAS GRILL 510.00
GAS IJNIT HTR $10.00
POOL IIEATER 535.00
VENTII.ATOR 515.00
THIS IS AN APPLICAT[ON FOR A PERMIT-NOT V ALID i JN'I'II. PROCESSED
I hereby apply for a b� pemiit and I acicno�� ledge that the information abo� e is complete and accurate; that the t��ork will be in
confotmance tvith e or anc and code ity of Fridley and ��-ith the Minnesota Construction Codes; that I understand this is
not a permit but niy a atibn for iit a work is not to start ���ith t a perniit;` that the �vo r�3�ill be in acco ance �vith the
approved pian � the c 1 rk whi requir eview and approval af p s.
SIGNaTURE OE _ PLICA ��"��R•i'I' I3.�-lE � � 1 l (
l-
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977