P - 45312Building MECHANICAL Permit No.: �
Inspections RESIDENTIAL APPLICATION Received By:1 � �e
763-572-3604 D���c`ci�� � ���
763-502-4977 FAX CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE (���Z' ���� YOURE-MAILADDRESS_ .�ONnG+�oV�qv� C'.. yAI►OQ.fQN'1
SITE ADDRESS ` S�� � r+�.O r% 37. �. f .
THIS APPLICANT IS: ❑ OWNER �7ICONTRACTOR
PROPERTY NAME: W1�q,�k e` �Aw�1 1�.c6� t� S
OWNER/ ADDRESS: S '� ��1'Ko ST. .1�/ �, CITY ���'�
TENANT � �� STATEyt� Z[P s�3
PHONE: %C7�j., ,S%Z" d % %
CONTRACTOR COMPANY NAME: CTr' D J�l eraT?n �' �'' 2
SUBMIT A COPY OF CONTACT PERSON: A p V i4
YOUR STATE STATE LICENQSE # � 7 7Ca EXP DATE
LICENSE WITH ADDRESS: a��� ���R. �+T. N• �„ CITY �5��� LA� Af STATE�ZIP,�..�
APPLICATION pHONE 7Ca ��% Sa • O$�f'� FAX
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEw J° n�PLACEMENT ❑ ALTERATIONlREMODEL
DETAILED DESCRIPTION OF WORK �cy7 r'fJt r1 A C�.. �' � C.�
FEES ARE BASED OlV $1�.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (iNDiCATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZElBTU
MFG: MODEL: SIZE/BTU
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
BOILER $35.00 FURNACE $35.00 lGAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 JPOOL HEATER $35.00
DUCT WORK $]0.00 GAS PIPING $10.00 VENTILATOR $15.00
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THIS IS AN APPLICATION FOR A PERM[T-NOT VAL[D 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 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 w�c equire v' and approval of plans.
SIGNATURE OF APPLI ANT PRINT NAME�J��I► f7b ✓Ia �"� DATE �'"�7 � la �
APPROVALINSPECTORSSIG ATURE DATE
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977