P - 44611Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / / ''
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMTf A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2010
� ��% YOUR E-MAIL ADDRESS
❑ OWNER /BEONTRACTOR �
NAME: �
.�wnxESS:S /oZ CL �_�1�
PHONE: �" D�- •�.
COMPANY NAME: l %L
CONTACT PERSON:
STATE LICENSE # D �' EX� DATE � Z
PHONE �
TYPE OF WORK: I � ��'�'
FAMII,Y
5 "Q �5✓i _ 'S FAX
❑ TWO FAMILY
❑ TOWNHOUSE
�PLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIl'TION OF WORK
Permit No.'�,
Received By:_
n��'��a� �-
FEES ARE BASED ON $10.00 PER FIXT[JRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL N[JMBER OF EACH BELON�
PROVIDE IiEAT LOSS CALC'S PER MANU 2006 ASffitAE HANDBOOK. �� D/ //JC�S SIZEBTU
Equipment Installed MFG: MODEL.
MFG: ���� �°I' MODEL: f�J M3 aig' d� SIZEBTU
I � � MFG: MODEL: SIZEBTU
_( A/C $25.00 _FIItEPLACE (GAS) $15.00 GAS RANGE/OVEN 510.00
AIIt TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 i�iEW GAS GRILL $10.00
_BOILER $35.00 �FURNACE $35.00 GAS iJNIT HTR S 10.00
`CiIIIvIl�TEY LINER E10.00 GAS DRYER $10.00 _POOL HEATER $35.00
_DUCT WORK $10.00 _GAS PIPING $10.00 VENTII,ATOR $15.00
�'"' ; .
�
THIS IS AN APPLICATION FOR A PERNIIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the informa6on 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 Constcuction Codes; that I understand this is
not a permit but only an application for permit and wor is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all ork ic requi es re ' and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME / d� f DATE I/" c�(/ � O
APPROVAL INSPECTORS SIGN�1 - DATE ' �'
�--`' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977