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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE l
SITE ADDTtESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
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PHONE:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER
YOUR E-MAIL ADDRESS
CITY
Permit No.:
Received Byt
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ATE ��ZIP��
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CONTRACTOR COMPANYNAME: f'�{�L S=+�L� I'1` � li
SUBMIT A COPY OF CONTACT PERSON: �'y' i� n1
YOUR STATE STATE LICENSE # Z-�S f 2 a(pc7 EXP DATE `n �I�
LICENSE WITH pDDRESS: i-7 a'.7 �^i� �2v��=�w �i'� /�- CITY Ws�JLSV �LLL- STATE Y���ZIP �/I �
APPLICATION PHQ� � j� _� 3 ou. � 3� J� FAX
PERMIT TYPE I�^�,�GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK:
DETAILED DESCRIPTION OF
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❑ REPLACEMENT
; l�5i
❑ ALTERATION/REMODEL
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 HRAE F�ANDBOOI{. ��-t ,, ^ ��_� / y���
Equipment Installed MFG: C`S�u �i`��'�Z��-C-. MODEL: �-t'/�� 3�/'-77 SIZE/BTU ✓_�_
MFG:
MODEL:
SIZE/B1'U
MFG: MODEL: SIZEBTU
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 $] 0.00
BOILER $35.00 _FURNACE $35.00 _GAS UNIT 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
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be i
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this
not a permit but only an application for it work is not to start without a permit; that the work will be in accordance with tk
approved plan in the case of all o k i eview and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME L��� �!(� •� � ��A�TF L(�C � 1
APPROVAL
TURE
TE
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977