P - 48156Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I � a
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY NP
OWNER/ �
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
����
Permit No.:o� 1�'t,��' �"°� i
Received By ��1��
��e��� �
CONTRACTOR COMPAxSt NA�: - 'I� '"
SUBMIT A COPY OF CONTACT PERSON• Q�L^^ �' n T�^ �-
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH pDDRESS: �D`ZO � �� �r'rv c'F�: _ C1 �. l STATE!Y!/�IP,
APPLICATIdN PHONE �/)SI�oZ�S -�%.�L� FAX Lc1S-I �o�c�S�`ja•.�l
PERMIT TYPE ��GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �a;REPLACEMENT ❑ ALTERAT'ION/REMODEL
DETAILED DESCRIPTION OF WORK _� � IG�-�' � `� � �' ° - ��� � -
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV4�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZEBN
MFG: ���j%la� MODEL: i.Z m H / SD � D SIZEBTU !� U
MFG: MODEL: SIZEBN
_A/C $25.00 _FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIREXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 �URNACE $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
!�1 .
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 licati n for a permit work is not to start without a permit; that the work will be in accordance with the
approved plan in the case w r 'ch re � s review and approval of pl ns.
SIGNANRE OF APPLICA PRINT NAM ATE - �� �
APPROVAL INSPECTORS SIGNATURE DATE
; City of Fridley `
ilding Inspections Department
University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977