P - 46551` Building MECHANICAL Permit Ivo.: �
Inspections RESIDENTIAL A�'PLICATION Received By:
763-572-3604 CITY OF FRIDLEY D��� �:
763-502-4977 FAX EFFECTNE i-1-2011 �
DATE 1 ' " -
STTE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNERJ
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
YOUR E-MAIL ADDRESS [JII 1 /
❑ OWNER �22
N�: D 1 I �
ADDRESS:
� �
PHONE:�p �j ���I "
COMPANYNAME: --�C%Q
CONfACT PERSON: j U
�
A
STATE LICENSE # ��v (p �' EXP DATE .�J � 3/ I Z� � Z
ADDRESS:������ �C� '�iil� " I%� � CITY ��/i JL�-- STATE � L�P��
PHONE�?> •�.%��' ��c'�' f --- FAX (�3—�1J-�--f��iftif
�SINGLE FAMILY ❑ TWO FAIvIILY ❑ TOWNHOUSE
TYPE OF WORK: I � ��' � �rLACEMENT
DETAILED DESCRIPTION OF WORK
❑ ALTERATION/REMODEL
FEE3 ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV� ,
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASIiRAE HANDBOOK /� r ` Q`'
Equipmentlnatalled IvIFG: ��_ MODEL: _ �� ✓ i%il�. SIZEJBTU IlldiDl�O D� `
!_ • MFG; , MODEL: _ SIZEBTU �
MFG: 14fObELi _ SIZEBTU . _
_A/C $25.00 __FII2EPLACE. (GAS� $15.00 _GAS RANGE/OVEN $10.00
AIIt TO AIIt EXCHANGEER $IS _FIREPLACE (WOOD) $35.00 . _NEW GAS GRILL $10.00 "
_BOILER $35.00 t!FURNACE $35.00 GAS UNTf HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35:00
DUCT WORK $10.00 _GAS PIPING $10.00 VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pernut 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 pernut but only an appl' ation for a pe 't and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case f a work w' h q' es re ' w and approval of 1 s. •
SIGNATi3RE OF APPLICANT � PRINT NAME ' �` S D%1 DATF 'l '� ���
-
-T��_
APPROVALINSPECTORS SIGNATiJRE � /i.(/ " \ na� � � ` ! ` {/
ity of Fridley
Bui i Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977