P - 44537Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECr�vE i-�-ZO>>
DATE � �� "�� � YOUR E-MAIL ADDRESS
SITE ADDRESS I.�% � /7�.�-�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
❑ OWNER
NAME:_ %.9 »� �r �4�-�✓v
ADDRESS:
PHONE:
COMPANY NAME: /F�f�J !' /� �J`�o( Tf
CONTACT PERSON:
STATE LICENSE #�� C} L-%�J' `-r� / j EXP DATE �S
ADDRESS%3�iv�/ �%Lca1i'�jIRK `,3'7"' CITY_�/��
PHONE �p � �� ' ,'yL `S� - (")�� FAX
,�SINGL$ FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEW �REPI:ACEMENT
DETAILEI� DESCRIPTION OF WORK :�;�1uGc�iCS�-
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
- � 9'!l
Permit No.:
Receiv�c� �,
�}a`t2�Re�' d:
/I
ATE Z[P.
TATE��ZIP � ��
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (1NDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
I A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN 510.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $1Q.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
�DUCT WORK $]0.00 GAS PIPING $10.00 VENTILATOR$I5.00
THIS IS AN APPL(CATION 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 1 work which requires review and approval of plans.
SIGNATURE OF APPLICANT ��Q�,�..c PRINT NAME/�� ��S S�C � DATE � OC ` I
INSPECTORS SIGNA
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977