P - 40730Building MECHANICAL Permit No.: '� �'�
Inspections RESIDENTIAL APPLICATION Received Byi !��
�63-s�2-3604 CITY OF FRIDLEY Date Re�' ���
763-502-4977 FAX EFFECTIVE 1-I-2011
DATE � ` �C% '-' { 1 YOUR E-MAIL ADDRESS �-?`�'�-�� (� • i�'e-r -`: �+�� �"� ✓� � �-� �
SITE ADDRESS .r� ._7 I� i% ",�2 fCR. �•j f�l C=r r
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
❑ OWNER �CONTRACTOR
NAME: �, � e +n Z �. n ,�
ADDRESS:
PHONE:
COMPANY NAME: N � �'z � � .
CONTACT PERSON: �'�: ---�.
TATE Z[P
STATE LICENSE # �4 2�`Jf /�7 � EXP DATE (2-' � 1�)Q" '1:. [ 2� 3 1� ll
ADDRESS: �0 `l' 1�% �`�1.�5 •55� e)� Q�va 1.1V✓ CiTY CA�'-^ rt��n(?. �( STATE'��i Z1P�"S �.33
PHONE � �2' SQS�' � ia� -F�1�C�
❑ SINGLE FAMILY � TWO FAMILY ❑ TOWNHOUSE
❑ NEW ❑ REPLACEMEN O ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK I�Z ���� Y� � �
. __ „ � '.. _ _ — h �' " l� $ � •a 5 �, �,� C o � p-t*' � � �, . ,� < - ,� ,�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTL)RES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
AlC $25.00
`AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG: ��"`��� MODEL: C. 2-3
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZE/BTU 7�%iVoO �-! U
SIZE/BTU
GAS RANGE/OVEN $10.00
�NEW GAS GRILL $10.00
�GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
TH]S [S AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 r qy' s review and approval of plans.
SIGNATURE OF APPLICA PRINT NAM��'�� Z~ �� �� �� DATE 7/r I��� 1 y) f
APPROVAL
DA
City of Fridley
�'uilding Inspections Department
' University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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