P - 48323Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � 1,3% / ��
SITE ADDRESS 7 � �
THIS APPLICANT IS:
PROPERTY NA
OWNER/ AD
TENANT
MECHANICAL Permit No.:'�u � : -
RESIDENTIAL APPLICATION Received By:
f, ; .
CITY OF FRIDLEY ���� � �� �' �
EFFECT'IVE 1-1-2012
YOUR E-MAIL ADDRESS !�` t'` ���2�.15 E� �1 �� f r'"' t'� �'t- • r� t
,�.���, D.�. �F�. � c.L,� , ,� �
'I� OWNER ❑CONTRACTOR
�.i C'a� �'�_ sf ti n. �n c.., �� e( f'e�: S
— 7 c�
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE _
LICENSE WITH ADDRESS: CITY
APPLICATION
PHONE FAX
PERMIT TYPE
TYPE OF WORK:
� SINGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
�� c�' �x.�„ STATE N�I IfZIP �� 3Z
❑ TOWNHOUSE
�ALTERATION/REMODEL
DETAILED DESCRIl'TION OF WORK J;/� $�� ll '�c�1l.r-���.� •� �� r'�'�k C�- ;� w_
STATE ZIP
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 AANDBOOK
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
B01LER $35.00 FURNACE $35.00 GAS IJNIT HTR $]0.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT 1��ORk $10.00 GAS PIPING $10 00 VENTILATOR �15.00
Number af fixtures r�7i $I0.00 x�10.00 -�
Nulnber of fixtures � $iS.Ofl � x $I�.OD;= $ � °
Number of fixtures � r$2S.OQ x' $25.00' $
Nuln�er of �xtures � $35.00 x $35.00��-- $
State Surcharg� — � 5.00
(NIIl�'I11�UM FEE ��O.QO) Tptal $__'��=
THIS !S AN APPLICATION POR A PGItMIT-NOT VALID UN'I'1L 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 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 o�� work whic '•es review nd approval of plan .
SIGNATURE OF APPLICANT L2'L��G � PRINT NAME � ' f� D'TE `�� �
APPROVAL INSPECTORS SIGNATUR :` D.��/ v/ DATE � /�
� City of Fridley
Bu' ing Inspections Department
niversity Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977