P - 84311Building
Inspections
763-572-3604
763-502-4977 FAX
DATE a' I �-���
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 1-1-2012
YOUR E-MAIL ADDRESS / V�1� C 8/'tf,
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❑ OWNER �CONTI
NAME: �bN I? /�
ADDRESS: � 7 � l. �
uun�.rF• '% � � " �� 7
COMPANY NAME:_
CONTACTPERSON:
STATE LICENSE #J
ADDRESS:��
PHONE / lo� �
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7J �� E`XP DATE � � �
t�✓ �/CC�fi ��i( CITY �-� S��Yi �
�SINGLE FAMILY ❑ TWO FAMILY
�NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
Fax %�3 j��/t�_
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
Permit No.a��a't�
Received By:'�! -�._-�-.--
Dat��' d���
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TAT� N/ ZIP�d
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�06�A'S�HRAE HANDBOOK. �V � S,�G��
EquipmentInstalled MFG: ir MODEL: SGk� SIZEBTU-��
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $IS FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
_B01LER $35.00 �FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS P[PING $10.00 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 11 wor1 wh' requires review and approval of plans.
SIGNATURE OF APPLICANT � /j"�--� PRINT NAME � DATE 6 0� � Z—.,
APPROVAL INSPECTORS SIGNA URE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432