P - 44945Building
Inspections
763-572-3604
763-502-4977 FA�
DATE / �
--•--�
SITE �DDRESS _
THIS APPLICANT IS
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 2-19-09
0
PROPERTY N,�,�:
OWNER/ pDDRESS:
TENANT
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAII. ADDRESS
conm:�rn rr.�¢: .,.a,,....,.. , ,.,,..,..� � . ... __.._._------.,
C'ONT�CT PERSON: Y �
STATE LICENSE # R 17_R7d_7� DATE
ADDRESS:
PHONE
F,�hIIL1' ❑ TRJO F.AhIILI
❑ NE�L' �EPLACEA•fENT
� �
DETAILED DESCRII'TION OF WORK
FAX
0
Permit No.:
Recei�-ed B��:
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CITY STATE ZIP
❑ TOVVNHOUSE
FEES ARE BASID ON 510.00 PER FTXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBII2 OF EACH BELO�
Equipment InsWled MEG: MODEL: SIZE/BTU
MFG. �/✓Yl�� MODEL: �l�,G SIZEJf3TU _�/ , �
MFG: MODEL: ��_ SIZFJBTU �
,�4/C 525.00 PLACE ( AS) S 15.00 _GAS RANGF/OVEN 510.00
_AIIt TO AIIi EXCHANGEER S15 A�E (WOOD) 535.00 NEW GAS GRII,L 510.00
BOILER 535.00 �Fi]RNACE 535.00 GAS UN1T H1R S10_00
_Q�IIQEY LINER 510.00 _GAS DRYER $10.00 POOL HEATER �i5.00
DUCT WORK 510.00 GAS PIPING 510.00 VENI�.ATOR 515.00
TFIIS IS AN APPLICATION FOR A PERMI't-NOT VALID UNTII, PItOC;ESSED
I hereby appl_Y for a building permit and I ackno • edge that the information above is complete and accurate; that the u�ork ���ill be in
conformance with the ordin es and codes o e � of Fridley and ���ith the Minnesota Construction Codes; that I understand this is
not a pemiit but only an plic o a pe it n �v°ork is not to start �v°ith t a permit; that the �vo - c�-ill be in acco ance with the
approved plan in the c e of k � h quir eview and approval of p .
v �l ��� 8
SIGNATURE OF APPLICANT PRINT N_�lE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977