P - 35413Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / � cY�
SITE ADDRESS �j
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRTDLEY
YOUR E-MATL ADDRESS
0 OWNER �(CONTRACTOR
NAME: �.-�.li.- `Sl �.\ 1�-�
ADDRESS: �DS 1`1 i � �. ��
PHnNE� /� /�1 -' S % � ` �CL
COMPANY
�
SUBMIT A COPY OF CONTACT PERSON: Y\ ' �-'
YOUR STATE STATE LICENSE # O�R, 3��p5�� '� �� EXP DATE n-
LICENSE WITH ADDRESS: �OS � `'�Y �7�-� \ � ��1e � CITY_
APPLICATION pHONE ip�' �' a�� "�i �'1 I FAX C1I � �"�
PERMIT TYPE
TYPE OF WORK: I O NEW
FAMILY ❑ TWO FAMILY
� 21 EPLACEMENT
O TOWNHOUSE
p ALTERATION/REMODEL
Permit No.: L a
Received By:
Dat��: � 11
` 1�� ��� �C �rY�\
STATN7! I ZIP
� STAT�NZIP �(a
DETAILED DESCRIPTION OF WORK ;�(2�''�O��l\ ZS `—�,"/0 �`C'�� �`P�(�" �\L�1T ��F"1
���r
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WIiERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOR
Equipment Installed MFG: ��r���(`1 MODEL: SIZEIBTU �,�
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 $]0.00 GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
_GAS RANGE/OVEN $10.00
_NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.OU
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID L3NTIL 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 all work which requires review and approval of plans.
SIGNA7'URE OF APPLICANT _�_�� r�. � PRINT NAME����:�.,� 'I� ���DATE �� I
�---T7,
' U City of Fridley
LBuilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977