P - 44942Building 1V�ECHANICAL
Inspections RESID�+ NTIAL APPLI�ATI4N
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE7-1-2010
DATE I � -° o� 3 -
siTE ADD�ss � v
TH1S APPLICANT IS:
PROPERTY
OWNER/
TENANT
YOUR E-MAIL ADDRESS
✓�(�� r�� F',a-�
❑ OWNER �ONTRACTOR
Permit No.
Received By:
�.�e�:-i1•
�
NAME: (r u 2.f' ��.1
ADDRESS: ��5� �Gl c.�v �_r ��(e.. ✓�i 1��.� r,� l� CITY ��2.< Q�� � STATE H� ZIP ss�f.�L
PHONE: "') 6 3,. �i 3 eL .�'7 0(.
CONTRACTOR COMPANY NAME: �� ,� a.
SUBMTT A COPY OF CONTACT PERSON: r/� y r3 y�
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: l�o� �' � �I D-C-,, C'lt- IU �. CITY �1L i.pJ � STATE l�+ ZIP SS .3
APPLICATION pHONE '1b3 iS� o7t4 5 FAx
PERNIIT TYPE
�E oF woxx:
�SINGLE FAMILY ❑ TWO FAMILY - [} TOWNHOUSE
❑ NEW �REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK _�V� �� A�
L
FEES ARE BASED ON 510.00 PER FIXTURE� EXCEPT WHERE NOTED. FIXTIJRES: (INDICATE TOTAL NUMBER OF EACH BELOVf�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: {{ A� L c,h MODEL: J A c.�.SO h�(( SIZEBTU
MFG:
MODEL:
MFG: MODEL:
_A!C $25.00 FIREPLACE (GAS) $I5.00
AIR TO AIR EXCHANGEER $15 _FII2EPLACE (WOOD) $35.00
BOILER $35.00 _FURNACE $35.00
CHIMNEY LINER $ I 0.00 `�- GAS DRYER $10.00
DUCT WORK $]0.00 T GAS PIPING $10.00
SIZEBTU
SIZEBTU
_GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS i1NIT 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 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 all work which equires review and approval of plans.
SIGNATURE OF APPLICANT C � r� �C'�(�J�J PRINT NAME � � r! ,� _n,r2 A �DATE 1 (�� � -' ( �
ALINSPECTORSSIGNATURE
�.,.�..--�`�, City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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