P - 44618Building MECHANICA�, permit rlo.: �
Inspections RESIDENTIAL AP�'LICATION Received By:
763-572-3604 �ITY OF FRIDLEY Ri��'� � � � ��0
763-502-4977 FAX EFFECTivE�-�-zo�o
DATE f�' � Q'� r� YOUR E-MAIL ADDRESS
SITE ADDRESS �`3 � ��L l � tJ � � t i
THIS APPLICANT IS: ❑ OWNE �CONTRACTOR
PROPERTY NAIv1E: /'� tt n,,a f, S C L. t,,� y� �(
OWNER/ ADDRESS: (_ 6 3 u U`"i �- �Z �� l�. SE cv l, CITY ��- <<4 �� k STATE r"� ZIP S � Y3 L
TENANT
PHONE: (9J' (—%'� S � l S( 1
CONTRACTOR COMPANY NAME: �'C..� v � � (�� (-.. ��4.��- �( l �o.. �,
SUBMIT A COPY OF CONTACT PERSON: C� ✓� � rR-t- �o _
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: Xd-� 0 T�t 0.�� S� ��, CITY (��-1 K1l STATI�"� � ZIP S� �( � L
APPLICATION pHONE 'j C,j '"1 S�f � l S°� FAX
PERMIT TYPE '�"O�GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE :.:;
TYPE OF WORK' � NEW �REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK T ��a l ( �L� �Qf �c_z �...:. ,�,-� �i.�,�c ,., ,o �.�
FEES ARE BASED ON $10.00 PER FiXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MAN[JAL J 2006 ASHRAE HANDBOOK
EquipmentInstalled MFG: '�� MODEL: 3SS �3aV D'-Ia06� SIZEBTU,�_
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
_A/C $25.00 _FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIRTO AIR EXCHANGEER $15 FIl2EPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 �FURNACE $35.00 GAS iJNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $] 0.00 _POOL HEATER $35.00
DUCT WORK $] 0.00 GAS PIPING $] 0.00 VENTILATOR $I5.00
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THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LINTIL 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.
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SIGNATURE OF APPLICANT C� ln � r� '� PRINT NAME C�n �( �"- O DATE
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APPROVALINSPECTORSSIGNATURE DATE
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f itv nf Fritllev
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977