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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