P - 37237Building
Inspections
763-572-3604
763-502-4977 FAX
DATE lJ � 7 �%
SITE ADDRESS ��� I�
THIS APPLICANT IS:
PROPERTY
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-20] 1
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�Permit No.�
Received By:
Date Rec'd:
YOiJR E-MAIL ADDRESS C3 �"� � �C /1�0.� �Pq �/'/1 � , ('O�'!
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❑ OWNER �CONTRACTOR
NAME. 'e !1 (\ a � i� �
TO NANT ADDRESS: �����C�� C%�� f�� CITY ��%'��'�'� STATEI��✓ZIPSJ�`�Z
PHONE: �lP .� �-- .5��'� "'��� C�p
CONTRACTOR COMPANYNAME. C''�i'�U.+4/ P�'1 �� F j�
SUBMIT A COPY OF CONTACT PERSON: /4 Q�/ a{ Yl
YOUR STATE STATE LICEN�SpE /# !y � EXP DATE
LICENSE WITH ADDRES3: U/ �C� 4�%�/i'�`� c�%: /�%Fi'��.CITY-� i—�n� L--��}°-Q. l��k,_$TATE�2[P�-S�Z
APPLICAT30N PHONE _ %(0.3 - �' � � ~ � g �� FAX ��� �' %S4 -- 7� �' Z
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK i_;f9/de'9
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTLIRES: (INDICATE TOTAG NUMBER OF EACH BELOW)
PROV[DE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: %`�M�'"�`' SIZE/BTU ��,� �
MFG:
MODEL:
MFG: MODEL:
A{C $25.00 FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
__DUCT WORK $10.00 _GAS PIPING $10.00
S1ZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
^NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
^POOL HEATER $35.00
V ENTI LATOR $ I 5.00
THIS [S AN APPLICATION FOR A PERMtT-NQT 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 Frid]ey and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for •mit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the se of all ork whic e ires - and approval of plans. / f�/ � a� /
SIGNATURE OF APPLICANT PRINT NAME ��'t� I 4✓��'� D E�"� ! 7 //
AL INSPECTORS SIGIVATURE
DATE
City of Fridley
Bu" ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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