P - 48192Building MECHANICAL Perniit Ivo.: - G' �(a
Inspections RESIDENTIAL APPLICATION Received By
763-572-3604 CITY OF FRIDLEY Date ��B J� �- �-
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE �/ Q' /� YOUR E-MAIL ADDRESS
SITE ADDRESS �'I�O� /�1/fs/ss/�/�� 'tT
THIS APPLICANT IS: ❑ OWNER ,�CONTRACTOR
PROPERTY N,�: �/,,� ,��EZ
EN�N ADDRESS: �S'� �a ^'=� v� S cr�rx ��e y.s7�L '' sTA� Nt Ir ss�5�a
PHONE: %/.�- ai%O- `%/d'%
CONTRACTOR COMPANY NAME: /i4/TD /�� �'��`� �� � J" �Rt��C�
CONTACT PERSON: � ���^�
SUBMIT A COPY OF �
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: 938J' ��LYST CITY L'C1�� R%�IJyS STATB�1/�IZIP.S�'�
APPLICATION pHONE O'%fv3- S% b" 7aW
FAX
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: ��W � �PLACEMENT ❑ ALTERATION/REMODEL '
DETAILED DESCRIPTION OF WORK SFT d-Vt �r W�ilB�R�^�� I= �Rti°��3t�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE IiEAT LOSS CALC'SPER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: ' SIZElBN
MFG: MODEL: ' SIZEBTU
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 QAS GRILL 510.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR S10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL �IEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 all work which req 'res review and approval of plans.
SIGNATURE OF APPLICANT r C PRINT NAME �`N% T���"��-� DATE f— I D-/a—
APPROVAL INSPECTORS SIGNATURE DATE
City of Fridley
Build g Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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