P - 47336Building MECHANICAL Pe�it No.: b � q�
Inspections RESIDENTIAL APPLICATION Received By:�
763-572-3604 CITY OF FRIDLEY Date Rec'd:
763-502-4977 FAX EFFECTTVE i-l-zoi i ��i � U � L 0'� �
n.a� // !(0-1/ Youx E-�L aDV�ss �i�.� �fil/�'I �7 ZooM . N� �
SITE ADDRESS SZ� NU��
THIS APPLICANT IS: ❑ OWNER j�CONTRACTOR
PROPERTY NAME:
OWNER/ ADD�ss: S2/ h�t1C�o crrx �Rll;�i�� sTa� zir
TENANT
PHONE:
CONTRACTOR CONtrANYNAME: R�N�V AT/o/�f J-fEATjNIo /1-Nl1 Gqds.��l �o J IV�'�_
SUBMIT A COPY OF CONTACT PERSON: ,B/L,L ,Q,E',Lt, �
YOUR STATE STATE LICENSE # EXP DATE
LICENSE w�� ADDx�ss: /�S/$ (jo .d y3.0 �.s ci� �� L�!-x.� sTaT�ziP SS3�
aPPLicaTtoN rxorrE %'� 3- Z Z1- 5y3Z Fax
PERMIT TYPE i�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT 1�1LTERATION/REMODEL
DETAILED DESCRIPTION OF WORK f},� A ,d UGT G�l �/QK � � 1�1 T/ aiC,
/VD �i��//�IC�(GE� _
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 HANDBOOR
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
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 GAS LJNIT 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
Number of fixtures @$10.00 x$1 Q.00 =$
Number of fi�ctures � $15.00 x $15.00 = $
Number of fi�ctures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ S.OQ
MINIMLTM F'EE $40.00 Tota1= $ " 4 �J `�
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 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 work which re uires r view and approval of plans.
SIGNAT[JRE OF APPLICANT �� ./� �l�j� PRINTNAME W/1-L-/I¢�{1 afLL►K DATE � I�l��'I I
APPROVAL INSPECTORS SIGNATURE DATE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR BUILDING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Iospections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977