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Inspections
763-572-3604
763-502-4977 FAX
DAT� Fo 'sl /-
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TH1S APPLICANT 1S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
r�uMr,1� �r'YPE
MECHANICAL Perinit No.:
RESIDENTIAL APPLICATION Receiveci By:
CITY 4F FRIDLEY D��'�-U
Erh'ECTIVE 1-1-201 I
� YOUR E-MAtL AUDRESS
�t /C ��1 /� �.
❑ Qw'NE1Z ONTRAC'TOR
NAM t: 1,/(Jti(�
ADllR�SS: ��6
PHON�;: �`�' /% L%
COMPANY NAME:�
CONTACT PERSON:
STAT� ��r i� L
�
ADDR�,SS:__��
PHON�; (!y�, �/ � �
GL� h'AM1LY
TYPE OF WORK: I� N���
DETAILED DESCRIPTION OF
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TY / /LJ C�FL STA
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LAC�M�NT
❑ TOWNHOUSE
❑ ALTERATIONiREMODEL
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FEN,S ARE BASED OV $10.00 YER F1X7'URH:, EXCEI'7' �VHERE VU'1'�,Ll. F1X7'URES: (IVDICA7'N,'P07'AL VUYIB�R OF �;ACH B�:LOW)
PROYIDN, H�,A"f LUS9 CALC'S I'ER VIAVUAL J 2006 '1-�RAE HAVDBOOK. y��j
�:quipment lnstalled MHG: (� — ,�'�v� M011�.L: �/ /�1 ��� SI'L�.iBTU ��
MNG: M011�L: S1'L�/BTU
MHC: MOD�L: SI"G�iBTU
�AiC $25.00 Fll2�PLACE (GAS) $ ]5.00 GAS KANGEiOVEN $]0.00
_A1R TO AIR EXCHANGE�;R $15 _ �s11ZEPLACE (W'OOD) $35.00 N�:W GAS GRILL $10.00
BOILtR $35.00 NU RNACE $35.00 _GAS UN IT HTR $10.00
_CHIMNEY L1N� R$ J 0.00 �GA S DIZY ER $10.00 POOL HEAT�IZ $35.00
_DUCT N-'ORK $10.00 GAS PIPING $] 0.00 _VENTILATOR � I5.00
THIS 1S AN APPLICATION FORA P�RMIT-NOT VAL1U UNTIL PROCESSED
I hcrcUy apply for a building permit and I acknowlcdgc that thc infom�ation abovc is complctc and accw�atc; that thc work will bc in
conformancc with thc ordinanccs and codcs of thc City of Fridlcy and with thc Minncsota Conshuction Codcs; that [ undcrstand this is
not a permit birt only an application for a pertnit and work is not to start without a permit; that thc work will bc in accordancc with thc
approvcd plan in tlic casc of all work which rcquires rcvicw and approval of plans.
SiGNATUKE ON APPLICANT P)Z1NT NAME i'\��1.� ��[�"�iJ �llATE (�"� y— j�
A]'PROVAL I VSP�;C"fURS SICVATURE _ DATE
City of Fridley
Building Inspections De�artment
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977