P - 48094Building
Inspections
763-572-3604
763-502-4977 FAX
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STTE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
D �
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
a.vi� i nAa, i vR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE #
LICENSE WITH ppDRESS ���
APPLICATION n, .z .,�
..
XOUR
PERMIT TYPE �GLE FAMII,Y D TWO FAMILY
TYPE OF WORK: a r�w �rr.ACE�rrT
G
Permit No.:
Received By:
nat��t: -� �11
��. 50�i U C_� F�'0 L�
F.4x -lto�-�r5�—
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILEQ DESCRIPTION OF WORK f� ��-�' �� �/�.OLLL..
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FEES ARE BA5ED ON 510.00 PER FLYTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICAI'E TOTAL NUMBER OF EACH BELOVV�
PROVIDE HEAT LOSS CALC'S PER MANUAL d 2006 ASHRAE HAIVDBOOK.
Equipment Installed MFG: MQDEL: SIZFIBTU
MF t MOD� � �` � �7 �^IU SIZE/BN `� � �� �
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $I5.00
AIR TO AIR EXCHANGEER S I S FIREPLACE (WOOD) 535.00
BOII.ER 535.00 �FCJRNACE $35.00
CI-mvINEY LINER S10.b0 _GAS DRYER $10.00
_DUCT WORK 510.00 _GAS PIPING $10.00
SIZFJBTU
GAS RANGFJOVEN SI0.00
NEW GAS GRII.L 510.00
_GAS IJN1T HTR $10.00
POOL HF.A1'IIt 535.00
VEIVTII.ATOR $15.00
, �, ..�..,.,. �� ., .�,......,. o „
Nurnber of fiactures Q 535.00 x$35.00 =$
State Surcharge = $ 5.00
�MINIMUM FEE $40.00) Tota1= $ ��} • �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge tliat the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of th ' of Fridley with the Minnesota Construction Codes; that I understand this is
not a permit but only an appli ' for pe i an or is not tart without a permit; that the work will be in accordance with the
approved plan in the c work which ' s re w an roval of plans. _
SIGNATURE OF APPLICANT
INSPECTORS SIGNAT[TRE
� City of Fridley
B ilding Inspections Department
643 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: ?63-502-4977
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