P - 48124Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �'� Z 3 � �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
0 � j' YOUR -MAIL ADDRESS
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❑ OWNER �CONTRACTOR
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Permit No.:��,:� �U�-' f I�� (
Received By: �% �
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Dat��d ��
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trL/x>� L.C'o�z,
NAME: �/V �/�I �
ADDRESS� D 6 /G� C/P��� � CITY L� STAT P
PHONE:
COMPANY NAME: �/�%(�j�SQ/� C�i fNG► 9f���%l �s
CONTACT PERSON: Si4X ��/`�f �/C,SO
STATE LICENSE # EXP DATE
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^�Z'��75' FAX
Rf SINGLE FAMILY O TWO FAMILY ❑ TOWNHOUSE
❑ NEW ❑ REPLACEMENT �ALTERAT(ON/REMODEL
DETAILED DESCRIPTION QF
A
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: MODEL: SIZE/BTU
MFG: MODEt,: SIZE/BTU
MFG: MODEL: SIZE/BTU
_A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN 510.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
�DUCT WORK $] 0.00 _GAS PIPING $10.00 VENTI LATOR $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 wi(I 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 ork which equires review and approval of plans.
SIGNATURE OF APPLICANT E��� /�/Hr.�"'— PRINT NAME �/"1'� /t1"f�f+�cS�/�DATE' 'ZZ' Z�iI�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977