P - 44534Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE ]-I-20] 1
DATE V_� �G�_�
3ITE ADDRESS?
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
�S,S� ,
❑ OWNER
ADDRESS
YOUR
�ANTRACTOR
Permit No.:
Received By:
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LADDRESS '-�V-�=J�--����C'c..�t ���.r C�,n.Y�C^!� �(,L�.
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CITY
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CONTRACTOR COMPANY NAME: 1 f2rn �'t�� �A` ✓ C- w,oc�✓��
SUBMIT A COPY OF CONTACT PERSON: ���V„�. (��� ytirn r
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS:�GI��\ � �0l„�1'�. LC��/r ir CITY�IQ�,C.1/ STATE�_►731P�,Z�
APPLICATION pHONE � (.i - � /02. — O'�o-1 FAX % `3 , a ba - q3`� a
PERMIT TYPE INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW �EPLACEMENT , LTERATION/REMODEL
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DETAILED DESCRIPTION OF W OR�fij e� 1s . �(` � d I u �� v�,� �,,,, �'
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT . E TO
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: .�,.Zr�_/r� MODEL: O I•�'
A/C $25.00
AIR TO AIR EXCHANGEER $15
�BOILER $35.00
_CHIMNEY LiNER $10.00
_DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $ I5.00
�IREPLACE (WOOD) $35.00
URNACE $35.00
GAS DRYER $10.00
�GAS PIPING $10.00
NUMBER OF EACH BELOW)
siz�aTU 6d urn�
SIZE/BTIJ
SIZE/BTU
GAS RANGE/OVEN $10.00
_NEW GAS GRILL $f0.00
_GAS UNIT HTR $10.00
POOL HEATER $35.00
_VENTILATOR $I5.00
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 f a permi and work is not to start withouT a permit; that the work will be in accordance with the
approved plan in the case of 1 or whi q ires r iew and approval of plans. /'
SIGNATURE OF APPLICANT L(, �°�_ PRINT NAME � V l �t (_ In�..p � �xd.�yNC+y`DA�E �/�� /76 Ll
APPROVALINSPECTORSSIGNATURE
DA
City of Fridley
� uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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