P - 44947�
Building MECHANICAL Permit No. `�
Inspections RESIDENTIAL APPLICATION Received By: r��
763-572-3604 CITY OF FRIDLEY ������ � � �'���
763-�02-4977 FAX EFFECTIVE 7•1-20I0
DATE ��:� `'�� YOUR E-MAIL ADDRESS �� �°'/A,F'' n��
si� �wDxESS '7 / l� � �,E �'a� k �X �R, c� ��'-�y � N
THIS APPLICANT IS: ❑ OWNER �(CONTRACTOR
PROPERTY N�: �� EC�. .+. q�e�( iGA.F m�
TNANT ADDRESS: rlI Il I C� LRrEF K�e4`� CI'I'Y I'R 1 I�LG S/ STATE�LIP �.3.�,
PHONE: 'IL��° -5� i l � (,2(.�ZO ol
CONTRACTOR C01vrnA1vY 1v�: T��4 h'1 J�FC H/t N 3C AL 2N�
SUBMIT A COPY OF CONTACT PERSON: f i7 i GN /�►E L [i � R. L.SD N
YOUR STATE STATE LICENSE # C� g Q�—oic�J'�O �i EXP DATE
LICENSEWITH ,�DRESS: �j508 SNELG/NG RV�. CTTY n%PI-S STATE�ZIPSSyDip
APPLICATION pHONE Lo l a.- �nZ�I " Sl¢ i{ io F.�L �.�a- "l a�- �.,z t,2SCQ
PERNIIT TYPE �GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK' ��W PLACEM$NT ❑ ALTERAI'ION/REMODEL
DETAILED DESCRII'TION OF WORK �3 l� ��V�
FEES ARE BASED ON S10.OQ PER FIXTURE, EXCEPT W$ERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�
PROVIDE IiEAT IASS CALC'S PER MANUAL d 290f ASHRAE HANDBOOK.
Equipa�ut Installed MFG: MODEL: $IZEBTTJ _______�_
MFG: :7� ^ MODEL: T °`"'�' ' StZEBTU �i �
MFG: MODEL: SIZEBTU
A/C 525.00 TFIREPLACE (GAS) 515.00 GAS RANGElOVEN $10.00
�AIR TO AIIt EXCHANGEER �15 _FIREPLACE (WOOD) 535.00 NEW GAS GRILL 510.00
�BOII,ER 535.00 FURNACE 535.00 _GAS iJNIT HTR SI0.00
CHIMNEY LINER � 10.00 _GAS DRYER $10.00 _POOL HEATER 535.00
�DUCT WORK 510.00 GAS PIPING $10.00 VENTILATOR $15.00
�`'�i11lltlCl' Of �llttUtES � �1�.�} X ��D.Q� _ $ ' `
Numt�er of fixtures @ $15.00 x $15.00 = $
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 � x $35.00 = $- �"'� `'�
State Surcharge = , /'� � $ 5.00
� / �
IIVJ[UM FEE $40.00 ota1= $ �
�� T S IS AN APPLICATION FOR A PERNIIT-NOT VALID UNTIL PROCESSED
I hereby apply �o�a-5uilding permit and I aclrnowledge 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 ihis 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 appmval of plans.
SIGNATURE OF APPLICANC G� PRINT I�IAME��f/Af�/ �J�SDJ'�HL DATE JI �� ID
ApPROVAL IDISPECTORS SIGNATURE DATE
PLEASE NOTE: SEl'ARATE PET�MITS ARE RE UiRED'FOR BUII.T311+1G ELECTitICAL AND MEGHANICAL ``�VC11� `
City of Fridley
Building Inspections Department
CA�1� TT�"�'_.._'a.' A_'_""..I�TT? T�.71__. 11AT GGA�1�1