P - 39806Building
Inspections
763-572-3604
763-502-4977 FAX
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLIGATION
PERNIIT TYPE
: � � � --��� �, .
MECHANICAL Perrnit rto.:�
RESIDENTIAL APPLICATION Received By:
CITY OF FRIDLEY D����'���
EFFECTIVE 2-19-09
�" Y E-MAIL ADDR�E,S/S
� t"fr�7C. C �.�s .��t�.l� '�..,� �` /y' �"' -
ADDRESS:
COMPANY
CONTACT]
STATE LTCI
ADDRESS: 74.021A/sch%p��p�enue CITY.
PxorrE �Edext Prair�e, MN 65�
1
TYPE OF WORK: I � �W
FAMILY ❑ TWO FAMILY
DETAILED DESCRIPTION OF WORK
�,�
❑ TOWI�IHOUSE
C] ALTERATION/REMODEL
� P�.a �' �' % � +°°"` �f
T'E ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMI3ER O� F�H BELO�
PROVIDE HEAT LOSS CALC'S PER MANU J 2Q06 AS BOOK. /� ^�,ro� /g/�.
Equipment Installed Mk'G: �yaGE_������,��� MODEL: c.9► �� "°� �� F t�/` ��S �TU o*"����^"''
MFG: MODEL: S3ZE/BTtJ
ly¢'G: MODEL: SIZEIBTU
A/C $25.00 FIREPLACE (GAS) $15.QQ GAS RANGEJOVEN $10.00
AIIt TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 �FURNACE $35.OQ GAS UI�IIT HTR $10.00
CHIMNEY LINER $10.00 � GAS DRYER $ iQ.00 POOL HEATER $35.06
DUCT WORK $10.00 GAS PIPING $10.00 VEN'I'II.ATOR $15.00
Number of fixtures (a� $10.00 x $10.00 =$
Number of fixtures @ $15.00 x $15.00 = $
Number of fi�ctures @ $25.00 x $25.00 = $_
Number of fixtutes @ $35.00 � x $35;00 = $ � "'�'�
��
State Surchazge = $ '.!0'" �
t'°"..-.�,.
(MINIMUM FEE 535.50) Tota1= $
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building peanit 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 application for rrri and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of a1L rk ' h r w,,�..Fec+i�w and app val of plans.
SIGNATURE OF APPLICANT � �� �y NAME �!i= . "'� �' �` ��, DATE N� � Q , ♦
A PPR(1V A i. 1NCPF('T(1R C ST(:N Tf TRR �� , DA� �, �,. � ` .
PLEASE NOTE: SEPARATE
v City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX:763-502-4977
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