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Building MECIiANIC:AL PermitNo.�VO b�U,��
Inspections RESIDENTIAL APPLICATION Received By:�_
763-572-3604 CITY OF FRIDLEY R��C��'� ,���
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE YOUR E-MAIL ADDRESS
SITEADDRESS l,�t'15 -�ltat.Kzer i�1a.Ge-
THIS APPLICANT I5: ❑ OWNER L9�ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
NAME:
PHONE:
COMPANY NAME:J
CONTACT PERSON:
STATE LICENSE #
PHONE�%(e.3' tJ'.� �d(4(p'l FAX
�NGLE FAMILY ❑ TWO FAMILY
❑ NEW �EPLACEMENT
DETAILED DESCRIPTION OF WORK
CITY -�Y' L d�CJld STATE
EXP DA'['E
�_CITY�'�
7la 3- 53L - �
❑ TOWNHOUSE
� ALTERATION/REMODEL
TATE /i'��IP
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOIC.
EquipmentInstalled MFG: C,;w►�tk MODEL: 7 M��$��� SIZE/BTU �v>°i"
MFG: � N�� MODEL: X�- I'l — � 30
MFG: MODEL:
7i A/C $25.00 FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 k FURNACE $35.00
CHIMNEY LINER$10.00 GAS DRYER $10.00
_DUCT WORK $10.00 GAS PIPING $10.00
SIZE/BTU ���✓
SIZE/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 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
confotmance 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 the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT �j ".Q�G`� ���^�.. PRINT NAME IC�-(� �;A�.✓�-1 N DATE I Z /6� o
APPROVAL INSPECTORS SIGNATURE DATF.
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977