P - 84268Building MECI3ANICAL
Inspections �SIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE ' U � Li L/
SITE ADDRESS /i
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMTT TYPE
TYPE OF WORK:
� YOUR E-MAIL ADDRESS
z� i//�' �r2�S � j)Y �
❑ OWNER �CONTRACTOR
NAME: V '�
ADDRESS: J��S !-!J/�,i � Y/es t �[
PHONE: %U � ^�� / ' UO I /
COMPANY
CONTACT P 1�eP ai�
STATELICEN a�n • • •� u TE
ADD�ss: ridiey, MN 55432 cITY
PHONE - r.J��AAe
�'3INGLE FAMILY ❑ TWO FAMILY
❑ NENV ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
Permit No.:ZO L Z'U
Received By: ► ' f� i
Dat��'�: r� °�� "�' � � �
�
TH �
TE ZIP.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXT'URES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHItAE HANDBOOK
Equipment Installed MFG: MODEL: SIZEBTU
MFG: �I'l!L(.0 MODEL: 1 � �� .CJ SIZEBTU
MFG: MODEL:
_A/C $25.00 FIItEPLACE (GAS) $15.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
_DUCT WORK $10.00 GAS PIPING $10.00
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS LJNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $ I5.00
THIS IS AN APPLICA'I10N FOR A PERMIT-NOT VALID LTNTIL 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 11 work which requires review and approval of plans.
SIGNATUREOFAPPLICANT PRINTNAME �/� Y� S ZG�D,P DATE l L� Z6 1a-
APPROVAL INSPECTORS SIGNATURE naTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
� 763-572-3604 FAX: 763-502-4977
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