P - 39786Building
Inspections
763-572-3604
763-502-4977 FAX
DATE��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
i �7� -�-/�
MECHANICAL Permit No.: �
RESIDENTIAL APPLICATION Received By:
CITY OF FRIDLEY Dat���'c1�-
EFFECTIVE 1-1-20ll
YOUR E-MAIL ADDRF.SS
ADDRESS: L /J � /,...,L'l� G
PHONE: Crtilr� � X lv /� "
CONTRACTOR COMPANY NAME: � ��� � '*
SUBMIT A COPY OF
CONTACT PERSON: ` � e ° �
YOUR STATE STATE LICENSE #_ 749� ���Skii!t1s��On AV8(itl@EXP DATE �
LICENSE WITH ADDRESS: ���� ��'�r��� M� �5�'� C Y
APPLICATION
PHONE _ ° FAX
PERMIT TYPE
TYPE OF WORK: I� NEw
FAMILY WO FAMILY
R �E .,AC6. +ENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
A
�
STATE ZIP
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTLIRES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU� �J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: l�'l�aT"y^. MODEL: ��"���� SIZE/BTU �G�%���
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $ I5.00 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 UNIT HTR $10.00
CHIMNEY LiNER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK $10.00 _GAS PIP[NG $10.00 VENTILATOR $ I5.00
� 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 a co s of t Cit and with the Minnesota Construction Codes; that I understand this is
not a permit but only an app 'cati fo p r work is not start without a permit; that the work will be in accordance with the
approved plan in the case all wo k hi ' es review and a roval of p] ns. `
1 7 !/, f
SIGNATURE OF APPLICANT , f. PRINT NAME � ��'�L�G�`'�fr� ;'ppTg_�yZ{ / / � �/
� ,� r �"7 �`�
APPROVAL INSPECTORS SIGN URE ,��' / DATE �./< .''�/� i�
/ City of Fridley /
Building Inspectio�s Department
643 ] University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977