P - 44204Building
Inspections
763-572-3604
763-502-4977 FAX
DATE IC��
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.:'�.� �l; Z I`���
RESIDENTIAL APPLICATION Received By: � `�� ��_
CITY OF FRIDLEY ���e�1
EFFECTIVE 7-1-2010
YOUR E-MA[L ADDRESS J �✓� ��C-C�V�'%�'` +_° , l7C�
� �z�.� n� b
❑ OWNER
NAME: I1f i iiSd 11
ADDRESS: Z'�'1 � i✓i CITY STATE ZIP,
PHONE: �fO� �� C���
COMPANY NAME: \ 1' �.�'������
CONTACT PERSON:
STATE LICENSE # EXP DATE
ADDRESS: ��� �����'1'" � �- C1TY STATE ZIP,
PHONE %6�J ?��"f' %�lC� FAX
�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �EPLACEMENT
DETAILED DESCRIPTION OF WORK
O 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 2.jL 006 SHRAE HANDBOOK rn� QLd�O D� �
Equipmentlnstalled MFG: �lh�f� MODEL: SIZEBTU �
_A/C $25.00
AIR TO AIR EXCHANGEER $15
_BOILER $35.00
_CHIMNEY LINER $10.00
_DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) S 15.00
�FIREPLACE (WOOD) $35.00
�FURNACE $35.00
_GAS DRYER $10.00
_GAS PIPING $10.00
S[ZE/BTU
S[ZElBTU
GAS RANGE/OVEN $10.00
NEW GAS GR]LL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTiLATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LINTIL 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 wiit be in accordance with the
approved plan in the case of a rk w ic�h quir�s r view and approval of plans. � � ,
SIGNATURE OF APPLICANT 1/V PRINT NAME f 1" � �� l�' �`^' DATE �v �_
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977