P - 41190Building MECHANICAL Permit No.:LG
IriS eCilOriS Received By:
p RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY Date ':� '� .
763-502-4977 FAX EFFECTIVE 1-]-2011
DATE �/fL U� rL CG %� YOUR E-MAIL ADDRESS J�� r'--����, �'S �� (� M �J I(_ � LG v�--�
SITE ADDRESS �� Ir-O Lj /-,1�} ��L- VJ "'(
THIS APPLICANT IS: �OWNER �CONTRACTOR
PROPERTY NAME: �A�'� F `J C� , �-�%Si
OWIVER/ ADDttESS: 5`� LG Ca ��� F�-�' r- �-t `�---_ ����-
TENANT � CITY �" � �/�- STATE �[P
PHONE: ������ J '�J� � �
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: CITY STATE Z1P
APPLICATION
PHONE FAX
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �C�O� i—'� 2N v� c}=L � � L.
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTL)RES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU J 2006 ASHRAE HANDBOOK.
Equipment Instailed MFG: � MODEL: SIZE/BTU o C� U L1
MFG: ��— MODEL: SIZE/BTU C� �� N
MFG: MODEL: SIZE/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 �FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $ I0.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS P1P[NG $10.00 UENTILATOR $I5.00
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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 appli ation 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 I work wh' uires review and approval of plans.
SIGNATURE OF APPLICANT �� �; PRINT NAME�AMCzS [�y f�J� ,�_DATE ���L. c�` �Z C: ��
APPROVALINSPECTOR IGNATURE DATE
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City of Fridley
Building Inspections Departme�t
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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