P - 47306Building ��CHANICAL P°�'t N°.:�-U �Z�'� �
Inspections RESIDENTIAL APPLICATION Receivea By:��
763-s�2-3604 CITY �F FRIDLEY Dat���a�6C�V ����
763-502-4977 FAX EFFE�TlVE 7-1-2010
DATE I �'��� YOUR E-MAIL ADDRESS bC '� ��n c�.i �3 ��F�'�,.f�('A v�� •C 0�✓1
SITE ADDRESS L
THIS APPLICANT IS: ❑ OWNER @CONTRA OR
PROPERTY NAME:��v,n � �E\a„n�E S��wctt'�Z�
OWNER/ ADDRESS: ��,5�, 11J\ F� a , CiTY �� �� �j�C i STA7'E Y1�i ZIP �.5 �1'�-
TENANT pHONE: ��'� �� K E5 " F�,� �i a`
_— _—_. ____ ___ _ .------ ____------__
CONTRACTOR COMPANY NAME:
CONTACT PERSON: Home Energy Center
SUBMIT A COPY OF - 2415 Annapolis Lane N#170
YOUR STATE STATE LICENSE #_ p]ymouth MN 55441 _
LICENSE WITH ppDRESS: 763-476-1990 fax 763-476-1143 STATE ZIP
APPLICATTON pHONE FAX
PERMIT TYPE �SINGLE•FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW C�2EPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK (���u� F�� c�na F
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMSER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Instafled MFG: MODEL: SIZF/BTU
MFG: �V�PCMn MODEL: � �GQM(�� SIZEBN � �, ��_
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $IS FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOIL£R $35.00 �FURNACE $35.00 GAS UNIT HTR $] 0.00
CHIMNEY LINER $] 0.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILA70R $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 tne CiTy of Fridley anci wiih the Ninnesota Cot�struction Codes; that I understar,d 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 app val of plans.
SIGNATURE OF APPLICANT T NA Q,� CM� ��A f�/ DATE t�' o�'�' � �_
APPROVALINSPECTORSSIGNATURE DATE ! � V —`
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City of Fridley
Buildin� Inspections Deaartment
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977