P - 44203Building
Inspections
763-572-3604
763-502-4977 FAX
DATE f V / 11
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
Permit No.
RESIDENTIAL APPLICATION Received By��, _
CITY OF FRIDLEY � �'�� �` � ����
EFFECTNE 7-1-2010
YOUR E-MAIL ADDRESS �7CJV'�'WIWiIF�Ck�I/��C:G� �' tu�
❑ OWICER �ONTRACTOR
ADDRESS: t''� C.tO�+ul�Kl JT � �l� CITY STATE ZIP
PHONE: �Z 10��
COMPANY NAME: � C� 1 ri ✓�R.. �Gt
CONTACT PERSON:
STATE LICENSE # EXP DATE
ADDRESS: ��.l � W1t31/l`�' ST n�' C[TY STATE ZIP
PHONE '7(n3 �£g�i 77lO FAX
�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 MANU J 006 A`HRAE HANDBOOI{. ��2 �D L�,c.,l� �
Equipment Installed MFG: MODEL: J Y� l.r� S[ZE/BTU ��
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
_A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGF/OVEN $10.00
AIR TO A[R EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 �FURNACE $35.00 GAS UNIT H7R S 10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPiNG $10.00 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 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 al rk yy ich r qu' es rev'ew and approval of plans. �
SIGNATURE OF APPLICANT PRINT NAME N��l/1� �^-' I�� �� DATE �
APPROVAL INSPECTORS SIGNATURE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977