P - 36954Building MECHANICAL Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:'��
763-572-3604 CITY OF FRIDLEY D��'����--��
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE �ecemJ�er 9� 2o i D YouR E-�. �D�ss t� m. so lbera a q�enm � l I s. com
siTE ann�ss � lp5`� Kr, S�'i n Ct. Fr; d��eV M A! 55�32.
THIS APPLICANT IS: b�OWNER OCONTRACTOR
PROPERTY N,�; � � � � �peY�
OWNER/ ,a,DD�ss: t(� 5 4 Kr� S-j-� r1 C'} : ci�r ��� a( � C V STATELI A�I ZIP SS�,3Z
TENANT PHONE: ir7(o� 57 �" y 1 0 5 Ce i �(7(03)1039 � S50'f
CONTRACTOR co�arrY rr.aME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WTfH A�DRESS: CITY STATE ZIP
APPLICATION pHONE FAX
PERMIT TYPE � SINGLE FAMILY O TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: ��W y{,�PLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK Ne�.J Fvf nQ C e Zr15'}4 I I
FEES ARE BASED ON S10.00 PER F'IXTURE, EXCEPT WHERE NOTED. FIXTQRES: (INDICATE TOTAL NUMBER OF EACH BELOVi�
YROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE AANDBOOR S 000
Equipment Installed MFG: Gmol MQ /1 MODEL: GA�C"iti%$ l( SS �X SIZEBTU
MFG: MODEL: SIZEBTU
MFG: MODEL: 5���
,A/C $25.00 _FIREPLACE (GAS) $15.00 ,GAS RANGE/OVEN $10.00
AIIt TO AIlL EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 ,�FURNACE $35.00 _GAS UNIT HTR $10.00
CHIl�IlVEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATQR $15.0(1
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I*itnnber af �iZtures �a $25,UQ. ` x $�S.(f4 = �
N�unber af i'ixtu�'es �a $��.U4 t � x $3�.UQ = $;�; �
State �urcharge = $ S,U(}
` a�M[J�� FF:E �a�f.l1U iqca.� � � °�°
THIS IS AN APPLICATION FOR A PERNIIT'-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 Construcfion 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 accardance with the
approved plan in the case of all wo w' re uire review and approval of plans.
SIGNATURE OF APPLICAN PRIlVT NAME L! MO I�I�I� �I� DATE /Z ZO/D
APPROVAL INSPECTORS SIGNATURE DATE
, ��` " � �i.F� ���4�`�``� ���.��i�,'. :'����i� ��� � . `�``� � - ' : � �+����` � �` �' ,�� x
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977