P - 45733Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (� � � '
SITE ADDRESS
THIS APPL[CANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-20ll
YOUR E-MAIL ADDRESS � u-(�el�i�"I.�QJ f!`
�. t��--�'l��Y?',JP /�I � -
❑ OWNER �CONTRACTOR
NAME: V\L(�—y � Ii L�=�
ADD[tESS:
�—`(. �.L� N .
PHONE: � Cj O�i � OZ� I�
COMPANY NAMG:_�� II (1 �-I-CY
CONTACTPERSON:
I. f:��/�Y
STATE L�CENSE #__�
ADDRESS: �� � L���I
PHONE �L� J'"�CJ�J'�J �
CITY
C .
Permit No.: 'L
Received By:
D��'��
�C� I LD�
AT�n�Z�P�Sy �a
EXP DATE
l l�1 �i CITY �/ lk' STAT��IZIP ���I
_FAX�(p� ��J—�SJ—I
I.'�SINGLE FAMILY ❑ TWO FAMILY
�NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
�
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 A HRAE HANDBOOK. /� r� V �
Equipment Installed MFG: �j MODEL: 1/ �S — ��7'�/�-�SIZEBTU �
MFG: MODEL: SIZE/BTU
N MFG: MOD�L: SIZEBTU
!�A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
A[R TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
�BOILER $35.00 �FUKNACE $35.00 GAS LJNIT HTR $10.00
CHIMNEY L[NER $]0.00 `GAS DRYER $]0.00 POOL HEATER $35.00
DUCT WORK $] 0.00 GAS PIPING $10.00 VENTILATOR $15.00
THIS IS AN APPLICATION F02 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 ardinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an ap licat'on for ermit and work is not to tart without a permit; that the work will be in accordance with the
approved plan in the case f 1 ork ic requires re i w and a roval of plans.
SIGNATURE OF APPLICAN PRINT ME (/4 W i S��S �-` � DATE "' —� I I
APPROVALINSPECTORSSIGNATURE � DATE
PT FACF N(1TF• CFPARATF' FRMTTC F RFf1TiTRFI> FC1R RTTTT.T)TT�TC'�'FT,FCTRTCAT, aNl�'MF . AN ..A ., �RK"''' '
` City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977