P - 46521Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /! �— � � — Z Q/�
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
/6 s/
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATtON
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
Permit No.:
RESIDENTIAL APPLICATION Re�ei�ed sy:�
CITY OF FRIDLEY �e�r�'�Ll Q�
EFFECTIVE 1-1-20] 1
YOUR E-MAIL ADDRESS _ Z�v (/)���,/G/1 �/�%£q. ��n� CUi"�
C.Sn. n r►� ,. _ c L
O OWNER
ADDRESS: � i S �
PHONE:
COMPANY NAME: AG��U7 /�C,-� �
CONTACT P�RSON: _�,/
TE/Y•✓ZIP
STATE LICENSE # EXP DATE
ADDRESS: �/�C7 .4r�-(1c.i 's� ° .t/� CITY SP� �n� /� /rC Y STATE /�W ZIP i5'�3
PHONE_�7 - it��—� 4C'f' FAX 76� -�?a — 7Z3�
�GLE FAIv1ILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK (3-,�-E� �/Cn��
❑ TOWNHOUSE
ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDiCATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZElBT'U
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) $15.00
_FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
_GAS PIPING $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 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 f the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for rmit and w rk is to start without a permit; that the work will be in accordance with the
approved plan in the case of all work ' h r quire iew d approval of plans.
SIGNANRE OF APPLICANT PRINT NAME �l �/ /�Uc.//� DATE �/' ��� Z��l
�
APPROVAL INSPECTORS SIGN URE _ DATE
City of Fridley .
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977