P - 44616�
Building MEC�IANICAI� Permit No.: � �
l��tions RESIDENTIAL APPLICATION Receivea sy:
763-572-3604 CITY OF FRIDLEY ���� 1���1�
763-502-4977 FAX EFFECTivE�-�-ZO�o
DATE j(-/ O- � O YOUR E-MAIL ADDRESS
siTE aDD�ss (� 6 3� 3`f �- i1 �,,,, ( t ,;(� e�� Fr� � ra (�«
THIS APPLICANT IS: ❑ OWNER l$'CONTRACTOR
PROPERTY c
NAME: R,� A(�( J C l� �� rl.r (
OWNER/ ADD�SS: �6 3 U �
TENANT 1�-��� � "� (`� � CITY F{e-t �0 � i STATE H�-1 ZIP O s Y� •L
PHONE: b j I-'7 7S - 1 S 1I
CONTRACTOR COMPANY NAME: 1e � i, ,. Ct �t, �i�n .� i— �( i.-Ir w. �
SUBMIT A COPY OF CONTACT PERSON: C� ✓� Z ��' i1� t�
YOUR STATE STATE LICENSE # EXP DATE
LICENSEWITH ADDRE3S: ll a9b �6`�`'� � �''� CITY F{tlr0f STATE �lw�ZIP6���1.
APPLICATION pHONE 7 b3 1 S�,1 1 q� FAX �
PERMIT TYPE �
INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW L�REPLACEMENT ❑ ALTERAI'ION/REMODEL
DETAILED DESCRIPTION OF WORK _�, y! s�t I 1 Rc.� (o. �.LS�,d. v�- F�ir.u.-� �° �'
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOR�
PROVIDE HEAT LOSS CALC'S PER MANiJAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: r �.� MODEL: ;� � s 13+4�% �y, 66b SIZEBTU V V+ � G C
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIItEPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 _FIItEPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 �FURNACE $35.00 GAS L1NTT H1'R $10.00
_CHIMNEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
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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 application 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 all work which requires review and approval of plans.
SIGNATURE OF APPLICANT ��-- �` �'� i" ti PRINT NAME �� DATE
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APPROVAL INSPECTORS SIGNATUR� � --- DATE � `
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Citv of Fridlev
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977