P - 36738Building MECHANICAL pe�nit rto.:
Inspections RESIDENTIAL APPLICATION Received By:�A�
�b�-572-3604 CITY OF FRIDLEY D��'� �' R 2�
763-502-4977 FA� EFFECTrvE i-�-ZOii
DATE � � � � -' �/ Y UR E-MAIL ADDRESS �I ,r.]�ry�n��, � �(pn..�
SITE ADDRESS �P r�D �_�'� (7f ����„�' D_
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR coMrarrY rra�:
i
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # O� 5�'/,y+-� EXP DATE �
LICENSE WITH ADDRESS: �� 7� a,l�•!� V� /�( l CITYi��„n�7� STATE�IIZIP��
APPLICATION PHONE '7/���j -�µ•►-� -9�'� FAX 7(� � � 11-t.�-� " �029
PERMIT TYPE �INGLE FAMII.Y ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: �W ❑ REPLACEMENT ❑ ALTERATION/REMODEL
DETAII,ED DESCRIl'TION OF WORK .{.�I, �� �,� ��p��i'�p d- ��
/ I.�ts 1.6�iY3d.G11- � 1- _ J n� O
�
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACIi BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL d 2006 ASHRAE HANDBOUK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZFBTU
MFG: MODEL: SIZEJBTU
A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIR TO AIIt EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL EI0.00
BOILER $35.00 _FURNACE $35.00 _GAS ITNIT HTR $10.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
��XtUi^CS`� ��U. lt ���.�0 �'� ` :i
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Nunnber af fixiures @ $i5.00 x �15.Q0 � $
Number of fixtures @ $25.0� x $25.00 = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge ° $ 5.00
IMUM FEE $40.00 Tota1= $ ri� ��
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 ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but oniy an application for a pe it and rk is not to start without a permit; that the work will be in accordance with the
approved pian in the case of all work which re uir review and approval of plans.
SIGNATURE OF APPLICANT RINT NAME %� DATE ����-1' ���
APPROVAL INSPECTORS SIGNATURE DATE ' �
rt.�as� Ne►�: s�� � � �o� sv�r.�nv� �t.� �c�:; �► �t�z�t��: ��c `
City of Fridley
Buiiding insnecti�ns Denartment
6431 University Avenue NE, Fridley, MN 55432
763-572-3b04 FAX: 763-502-4977