P - 46479Building MECHANICAL Permit No.:
Inspections RESIDENTIAL APPLICATION Received By��
763-572-3604 CITY OF FRIDLEY Da��'c�: " �
763-502-4977 FAX EFFEC�v� 1-�-2011
vn� �_�(/ d o� 1 YOUR E-MAII. ADDRESS i S�+v `7 rs ��,ul� t� � ��--•
SITE ADDRESS %b� iy: � tis5 ��p�2i �•et �7`
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY NAME: 1�e,✓,�.:s 5..,�; �G
TE�N� N� nnn�ss: ?63 r r�ss:3si,�,o: Sr.�e�� ci� �"� sTn'rE��irn�'�
rxor�: � �3 - ,s" �� - .s"3 �o
CONTRACTOR COMPANY NAME: I�'1 i NJ.�Je,S s� `.n/ii(/
r
SUBMIT A COPY OF CONTACT PERSON: B
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: /O70/ r7'��J .�9v.= .�tJ �,s'r.,f� B CITY �yA�l� �.rpy.- STATE�.�ZIP_,�;���
APPLICATION pHONE 7,63 f�o! 3 o�.�J �- 300� FAX
j�' ��S' S/�S/-�17C7
PERNIIT TYPE ��GLE FAMILY ❑ TWO FAMII,Y ❑ TOWNHOUSE
TYPE OF WORK: � �W � �PLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �,4�4 E � �'�„�� , � ���,� f-n� �% C'� d ° /�dC ���4C .
FEES ARE BASED ON $10.00 PER FIXTIJRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASIIRAE AANDBOOK.
EquipmentInstalled MFG: �g� a.�,�- NtoDEL:3s�d�g��zs�to6o SIZF/BTU GiE'i_f.L�i
MFG: MODEL: SIZEBTIJ
MFG: MODEL: SIZE/BTU
_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
BOILER $35.00 �FURNACE $35.00 GAS UNTT Ii1'R $10.00
CHIMNEY LINER $]0.00 GAS DRYER $]0.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTII,ATOR $15.00
Number of fixtures @ $10.00 x $10.00 = $
�a�
3s•
Number of fixtures @$15.00 x$15.00 =$ S: i
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 x $35.OD = $
State Surchazge = $ 5.00
UM FEE $40.00 Tota1= $ O. �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN"I'IL 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 a11 work whic quires review and approval of pians.
SIGNATURE OF APPLIC PRINT NAME _�-a� ��7`�^5 DATE //���d/�
APPROVAL INSPECTORS SI ATU DATE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR BUILDING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977