P - 44948Building MECHANICAL Permit No.:'
Inspections RESIDENTIAL APPLICATION Received By:,�J���
�63-s�2-3604 CITY OF FRIDLEY Dat�c�t: �
763-502-4977 FAX EFFECTrvE �-i-zoio
DATE /oI/a�//O YOUR E-MAIL ADDRESS �r�g Q��✓� t p c �[�,a.�
SITE ADDRESS //Q /�iC.��f�[1 �.eaae� 1t%E
THIS APPLICAN'T IS: ❑ OWNER L�ON1'RACTOR
PROPERTY N�: �r,� Na . _ �� > _
�W�� ADDRESS:�/er� A�iCt��'tQ iC°,Q .tlt CITY T�e�d e..� STATErI�JLIP�/�
TENANT PHONE: %�tS' S i/-�-lf��„Z
CONTRACTOR co�arn rr.�: ay�, �,(f,r.f� �'.a� C�.�7-�1 c
SUBMIT A COPY OF CONTACT PERSON: T_�i�� �'iJ� S
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ,�DRESS: /e�o� q3'�0 �i�F ��� CTi'Y ���(��,�► STATFrN_�ZIP�
APPLICATION PH�NE �, ��(�3 S� 3 FAX t/
?6,3 S� S X---Qd 7�3 ,_J�-�'9_Zt7
PERNIIT TYPE �SINGLE FAMILY ❑ TWO FAMII.Y ❑ TOWNHOUSE
TYPE OF WORK• � �W ��LACEMENT ❑ ALTERAITON/REMODEL
DETAILED DESCRIPTION OF WORK � ,A,���-
FEES ARE BASED ON S10.00 PER FIXTDRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi�
PROVIDE IiEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: RtTvA,e�f MODEL: ��p�bpfclD SIZEBTU (oO,OfJ�
MFG: MODEL: SIZEIBTIJ
MFG: MODEL: SIZE/BT�3 . .
A/C $25.00 _FIREPLACE (GAS) 515.00 GA3 R:��iEiF.l43
AIR TO AIR EXCHANGEER $15 FIREPLACE (WQOD) $35.00 NEW CsA�'E�RiE.�:
BOILER $35.00 �i FURNACE $35.00 _GAS UNiPf F3'T!f TIa.O�
_CHIMNEY LINER �10.00 � �GAS DRYER $10.00 POOL HEATSt�$35.00
DUCT WORK $10.00 GAS PIPING 510.00 VENTILATOR �15.00
O� �'�`i��.� - X ���i � �'�__-____�--- ' � � ' �, �` � x ' ` �«��� �
_� ., �' ;,;X;
Ntunbe� of � �?a $15.� x $I5.00 = $
Number of fixtures @ �25.00 x $25.00 = $ `
Number of fixtures @�35.U0 x$35.00 =$ `' v
State Surcharge = $ S.OQ
�
FEE $40.0(i Tota1= $
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the informafion above is complete and accurate; that the work will be in
conformance witl� 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
appmved plan in the case of all work which uires review and approval of plans.
SIGNATURE OF APPLIC PRINT NAMF,� �Y{� Sj'ci /c c vC DATE ��� S//�
APPROVAL INSPECTORS SIGNA DATE
I'LEAS� N�TE: SEi'ARATE PERIVIITS ARE �CE UIRED FE)R BUILD► ELECTi�CAL , :. „ ';
_,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977