P - 37486Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� � l �
SITE ADDRESS �%
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Z C��� I�
❑ OWN
YOUR E-MAIL ADDRESS �.1.� �t✓�►►'"� 1
i�� �'z-
❑CONTRACTOR
Permit No.:
Received By: �
" ..���
Date ��
NAME; VG����► ( Fl��
ADDRESS: �� C�G+.L 1�'..c..� +}' Vl r CITY ��r-�.� STATE Y1t� ZIP S' J�
PHONE: �G 3 L� � d1 (p� 3�
COMPANY NAME: I� KJbil`k� �tyl' �j'�Gi V'► ,� �'1L
CONTACT PERSON: �Twt._-
STATE LICENSE # EXP DATE
ADDRESS: JC�� �"��.v`�'►tic5�'1�' `r�� i�� CITY ri'� STATEMhZIP ��47J�
PHONE FAX
�SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: �NEW C�EPLACEMENT
DETAILED DESCRIPTION OF WORK �� �G,G.�.
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTLIRES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAG J 2006 A RAE HANDBOOK.
Equipmentlnstalled MFG: '�rF}Q/'�i� MODEL; N13RLO(pQ� S[ZE/BTU LUVti
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
AIR'f0 AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 �FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
_DUCT WORK $10.00 GAS PIP[NG $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 ]S 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 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 ork vuhi h requ' es r vie nd approval of pla s. �, �
_ � � �� � � (1
SIGNATURE OF APPLICANT PRINT NAME ��l �' DATE `-�
AL INSPECTORS SIGNATURE
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
011