P - 60359�
Building MECHANICAL Permit No.:
Inspections RESIDENTIAL APPLICATION Receivea By:
763-572-3604 CITY OF FRIDLEY Date Rec'a: �— l—1
763-502-4977 FAX eFFECT�vE �-�-aoiz
DATE y I'Z YOUR E-MAIL ADDRESS ��Cl�TL; i.�� (.TPJ, it�✓l C.L �%Y<rC�Jlli/. �La-�-
SITEADDRESS ��� � !j�(sV��% 'St �fL� �i^�t���T�1 h�y3�
THIS APPLICANT IS: Y�OWNER OCONTRACTOR
PROPERTY NAME:
TO NANT ADD�ss: ��I� ���,�� V 1�(. �;� %� CITY ' STATE�i�ZIP �,�3�
PHONE: � 3�? Z Z�� 7� 7�
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: CITY STATE ZIP
APPLICATION
PHONE FAX
PERMIT TYPE �' �'NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK � 1�13�7 • r
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HAIYDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: S IZE/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 FURNAGE $35.00 �,F AS UNIT HTR $10.00
_CHIMNEY LINER $10.00 GAS DRYER $10.00 • LPOOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 �/ VENTILATOR $I5.00
Number offixtures �a $1�;�0 " �t $`10.OU'= $
Nurnber of fixtures �a $15.00 x $15,Q(l = $
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Number af fixtures �$25.D0 x$25 xQQ; —�
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Numb�r 0�`�xturas �,,7a $3�.Qt� a� $�� UQ� , $ , '` �� � ����i ���I� �
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MINIMUM T��'$�{O.OQ "�"C)fR�, -$ ,.� m
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
( 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 1 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 requires review and approval of plans.
SIGNATURE OF APPLICANT '% �C/r✓� PRINT NAME C'/�� / ATE �( / 3 / L
APPROVAL INSPECTORSSIGNATURE DATE
� � � . �' � � z� � :, di ' :" " ,^ ����er�u� � � 1� ; . " ��rtc�� WciRI�
���n��r�t�T� _s� � . � � .
i of Fridley
Buildin nspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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