P - 37117Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ' �- � I G�
SITE ADDRESS J� 0 �(j� U
THIS APPLICANT [S:
PROPERTY
OWNER!
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
MECHANICAL
RESIDENTIAL APPLICATION
CIT� OF FRIDLEY
EF�'ECTIVE 7-1-2010
YOtJR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
NAME: K V�'�.,�� ``7 �lZ��IA{�� �=S
ADDRESS:?jrl� 1—i,��ll t�;�'. l�� �• CITY
PHONE: �%% � __ `_ Z �=�2 _� `7 �� 3 '�1 _
COMPANY NAME:
CONTACT PERSON:
r�
Permit No.:
Received By:
�. ��--`.
��
T��ZIP �.i; t�,3
STATE LICENSE # EXP DATE
ADDRESS:� jl� j �.R�E')SST�"�'4'° .�✓L.,t/d� C[TY � P+.�'� L.A��-''L.- STAT �"ZIP�����
PHONE % �3 j �`�3` �� � � FAX
FAMILY ❑ TWO FAMILY D TOWNHOUSE
TYPE OF WORK: , � NEW �REPLACEMENT
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF W ORK 'rZ `� I� ���� y�i,�+'t.�,1 p
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACFI BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU L J 200b ASHRAE HANDBOOK. /�
Equipment Installed MFG: �� M��A_ MODEL; (.� S O% (3 � �%}� SIZE/BTU (S"/ 9/���
MFG:
MODEL:
MFG: MODEL:
A!C $25.00 FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 �FURNACE $35.00
CHIMNEY LINER $]0.00 GAS DRYER $10.00
DUCT WORK $10.00 lGAS PIPING $10.00
S[ZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
�NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $I5.00
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
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 fo a permit nd ork s not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work ic r ui es re ie and approval of pla ns. ,
� �.
SIGNATURE OF APPLICA �� PWNT NAME � ` � � '�`�� { � � �� DATE � � ��
A
i?A'
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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