P - 48012Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE �-,-ZO� i
DATE !� -^� °` � ` / �
SiTE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WiTH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
/� ° �-n�s�6,��G� �� -
❑ OWNER �[�ONTRACTOR
NAME: �i/�L�[� ��Qia,� �e�,
ADDRESS: J S�� �� �/�e
PHONE:
Permit No.:���
Received By: I�Y� I'
Date��l: ' '��
� ��--�L- � �
STATE ZIP ����
COMPANY NAME: as JI/Z lP f� ` u
CONTACT PERSON: __ �q,�f L,�. Z�� r�r
STATE LICENSE # EXP DATE
ADDRESS: �O�` 7 1, �pyc.{/F� �E. , CITY /v 7�&- STATE ZIP���
PHONE L ���_ ,3(jd,3 FAX
L] SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �EPLACEMENT
DETAILED DESCRIPTION
Ci�, L��s
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
E
FEES ARE BASED ON 510.00 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: ,�!d2,y. /f3^-g-- MODEL: C°5,1[-„� �•-�� SIZE/BTU _,�Q , at/rJ(J
- 7 ---•� _�_
MFG:
MODEL:
MFG: MODEL:
_A/C $25.00 _FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
_DUCT WORK $]0.00 _GAS PIP(NG $10.00
S1ZE/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-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 wiil 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 appl' for a permit an work is not to start without a permit; that the work will be in accordance with the
approved plan in the case o all wor which requ' s ' w d proval of plans.
SIGNATURE OF APPLICANT ' PRINT NAME [/,A+�/ �-� �/C [(el� DATE C 1 I��/!
APPROVAL INSPECTORS SIGNATURE n n-rc
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977