P - 39986�uil�;ing
Inspections
763-572-3604
763-502-4977 FAX
DATE �
SITE ADDP.ESS �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
�
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER f�'ONTRACTOR
.� Q ` --�
Permit No.:
Re�e��ea By:
Da�9�'d��. � �� �
r
ADDRESS:, ZrI ��� C"C''_ � 1�('P �. � t�� CITY �/{r� lC�,,1 STATE�ZIP-`j ��-.,_,
PHONE: �i=��-•`��I'" ���J
CONTRACTOR COMPANY NAME: �iP ('t x'1C i��-�S'�C�!_'�' �` ��`(�nb � �(lG , �-�-P17�-�i YiC:1 �- �✓
SUBMIT A COPY OF CONTACT PERSON: �Y�1Yi��`� GL ����rl
YOUR STATE STATE LICENSE #�/((%Z� /— �M EXP DATb
LICENSE W1TH ADDRESS: ��Cfi2- �hC��-�'l ��i� N�- CITY �•I �1�C�().Q �__STATE�ZIP J����
APPL,ICATION pHONE � tL'�`-�-t2� '���� FAk —] �3 "`LiZ� " ��� 3-�j
PERMIT TYPE
TYPE OF WORK:
,�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �REPLACEMENT
❑ TOWNHOUSE
➢1 ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �f'�r^��.o �jjri '�Z� Y fl(. C-c ��c�C ����LtC� (,v� Y�UJ
-��,r�n c�C-� � � � L
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: �r9 �-c Wi u,.h MODEL: �CU ll3� � � S.� � SIZE/BTU � Z� n
MFG: ����Vi MODEL:'��S i�'�1��I2.MPI1}t SIZE/BTU ������
MFG: MODEL: SIZE/BTU
�A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $]0.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 �FURNACE $35.00 GAS UNIT HTR $]0.00
CHIMNEY L1NER $10.00 GAS DRYER $] 0.00 POOL HEATER $35.00
DUCT WORK $10.00 _GAS PIPING $10.00 _VENTILATOR $15.00
x$1�:00=$
x $25,00 = $ �-�`' � �
�x$35.00=$ �S.Q�
I _S�a"���`� V�7 �
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 nof to start without a permit; that the work will be in accordance with the
approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF
APPROVALINSPECTORSSIGNATURE
PRINT
DATE
PLEASE NOTE: SEPARATE PERMITS ARE D FOR BUILDING, EL�,LTKI(>.
ity of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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