P - 48236Building MECHANICAL Permit Ivo.:26'� �L-'(:�(;1� ► �{
Inspections RESIDENTIAL APPLICATION Received By:.MA'�
763-572-3604 Date Rec'd: ' " `�
763-502-4977 FAX CITY OF FRIDLEY �,�'} ,�, .E, �, '�
EFFECTIVE 1-1-2012 �_� �.! '
DATE �✓ �— �J^— ! � YOUR E-MAIL ADDRESS
SITE ADDRESS SS 5Z� //// C� /:S 7'��.+E'_ �C�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NpME:
OWNER/ pDDx�ss:
TENANT �5 �� ��'""' � �� ��CITY STATE ZIP
nunwTC. �� / % % L/ % 2 — L/-7 7 �
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #
ADDRESS� OO /��
PHONE/ ��
7 /> �Oli� � G EXP DATE
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�"t� T � L� FAX
�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
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/�/G�� YZQ- -STATEi���IP�3z/3 y
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �J ������h �=d��-c1 /�"7 l� �''--�7�
FEES ARE BASED ON $10.00 PER FLXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $] 0.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIYING $10.00 VENT]LATOR $75.00
`Number of�xt�u-es �� �I0.00 `� � $i0.00 - ���`� ��
Number of fixtures �a $1�•00 x$l 5.00 —$
:tures'� $ZS.Q�
State Surc�7arge = ' , $ � � 5.00
' � ,,., ..
�
(MINlMU1VI F�E �40 00) Totat— $ ' �� ��
"CHIS 1S AN APPLICA110N FOR A YEKMIT-NO'C VALID UNTIL PROCbSSL-:D
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 requ'res review and approval of plans.
SIGNATURE OF APPLICANT �%'" " �'�� PRINT NAME S/"l /✓ /� !� � G�L �ifdATE O� — C� � —�
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977