P - 42134Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE ��j�, � }d j� YOUR E-MAIL ADDRESS I�JW I+.� . �� �t
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SITE ADDRESS I�iW's' r1 i�. y.. � R1 A�G'
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
NAME:
ADDRESS:
r
PHONE: (� 3 S"C � (KeC' � `�
COMPANY NAME: SAIs.q/ I+I.i.,..�.� L
CONTACTPERSON: �„J� V� S�Jt.�
�STATE LICENSE # SOk � � � EXP DATE
enno�ce• /_K"u4 1 U�d�• �_ _ ,
PHONE
EAMILY ❑ TWO FAMILY
0 NEW ❑ REPLACEMENT
FAX
Permit No.:
Received By:
D���'��� � � ��
A'kil�.
Rn�a�al�lQ STATE,�/1.�ZIP �/ l3
ATE 1M�Z1 P �l%�'
❑ TOWNHOUSE �A�,y.a �-p ,� aq sa r t
F�
ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �"r+�,�,3-�► y Suee l: tS �� eZ R4 ,�.5
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZE/BTU
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BO(LER $35.00 FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
f�DUCT WORK $]0.00 GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-N07' 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 all w•k which requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME B� V' SJ�,zC _DATE � QG� i-e�� �
AL INSPECTORS SIGNATURE
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977