P - 44862Building MECHANICAL Permit No.: G��(�
Inspections RESIDENTIAL APPLICATION Received By: �
�63-s�2-3604 CITY OF FRIDLEY �t��� � 4 011
763-502-4977 FAX EFFECT�vE �-�-zo>>
DATE � �Zy � � , YOUR E-MAIL ADDRESS / fr'��-� � � y� �- �a � G L ���"��� �U�+I.�
SITE ADDRESS ��!7 ? v � sg���- 1�� ��-tQ 1,.� ./Vl n,l 5 4 C( lj Z
THIS APPLICANT IS: �OWNER �CONTRACTOR
PROPERTY NAME: {- ��- �"��> ��5%�
OWNER/ ADDRESS: I�2 � U D�i�*2.n1� I�
TENANT C�T�' �R"� Q�'� STATE� ZIP S�L�3
PHONE: C95 ( 7A g$ 8ZS
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: CITY STATE ZtP
APPLICATION
PHONE FAX
PERMIT TYPE � SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: p NEW ❑ REPLACEMENT �ALTERATIONlREMODEL
DETAILED DESCRIPTION OF WORK �D'L 6�}-ir(K.aa� �KH/�ST /F�-"J t�� K�;
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL IYUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
_A/C $25.00 FIREPLACE (GAS) $I5.00 _GAS RANGE(OVEN SI0.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $]0.00
BOILER $35.00 FURNACE $35.00 _GAS UNIT HTR $i0.00
�HIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
CT WORK$10.00 GAS PIPING $10.00 ' VENTILATOR$I5.00
� ��= �- t��
,� �� � � . �. �,� � � . ? g e� 4 N � �
a . �; ,,. �,`� ^f �S � ,��� ,s �° � ; �.,"� ; �5 ,� � 'h�� �
m � � r
� �` ��' � � �, � '�"'� y a �"�r �a #
�� r �'� y�,�? ;, 4�' - f� �. a � i`f � `� � � �� �������`� '� a�.�k�+� � � ��. , A� �i:
k�, � � � � �r � �i',^ � " � �ti�, A ,�n. Cs � �
�M �� C� �1 k a 5 8 .� � �`� � � j� `F ���,:" x 4 �� Y :v .
�» � �� �� ������ ���� ���� �� 3� ���� � ��
£�� k � t �� ,, a � ��a � 3 1 �..
�' � �: �� � �, � %3�.� i � �. , ��,�, $%�,,,,��3 S vd�`�' � �t. � �� .h'� � �� '� � '� �t �� ��.� _ i ::
� , d2 ��. �� �� � `�' c�." � ,� � � �,�� �`��,"� +�` � � .� �:� '���� � � a � � � �' � r� �� �.w
�- � � � �L �. �� ;�.� �`a. � 5 � �. '� � 6 �, �
x: ; �. � .�, � u ;��- ���s��?��� �� a� . � � A ��, � � � � � i� c �"^ �a� V , ,� $ �`
� fi°� � � �� � m�� �. � �. �s � �' � � � � k 2�3 � `�`o ��.� �' 3 � � v ,
� � � � � y�� �� � � z ��� �R�� ����� � ��� �� ��� ��� f
������`� � � x �'��� a � �1� ���� x�� ������ � �� �, � � �� � -� � � �`�'� � �`^"� �} � �'� ��&� : � ��` �`'� ��. � , � � �.
�, R� � �,fit� a� m `��` *� c � � � �` ,a" �`� �s �'� � '�' � �
' � ��i, ,��'i '��' �'�^ '� i'� ^m� S�. ���� z� h . �, � � �. � -� �. � � : '� .� �,� � � �- �� �� `� � � ✓y ��,� � � �4e�����
� ..�l, z . ���� �� � � � � � �M1S � � t � �'.. � .. , .� � i �` Nf � ,� ,C � ,� � � �
...� ......... . .... _.. .., �, , ..a . ��.z�z, , , t�'..�,. �s , _. �, ... ��:� f , .�`i ��H� .: `;°� �: �� .?w! v � ��
.�'` .� .,,4� :,� , k�
THIS IS AN APPLICATION FOR A PERMI7-NOT VALiD UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information abave is complete and accurate; that the work will be in
conformance with the ordi ces nd codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an pl ati 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 casef�of 1 rk which requires review and approval of plans.
SIGNATURE OF APPLICAN � PRINT NAME P��' >��� C"�/ �5� DATE `'� - Z����
APPROVALINSPECTORS GNATURE DATE
k ���''"" F . ,. �.�.a :,
� ;� �4,�:,� �I.
t�ity of 1+'ridley
Building Inspections Department
6431 University Avenue NE, Fridfey, MN 55432
763-572-3604 FAX: 763-502-4977