P - 44958Building T MECHANICAL I Permit No.�
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-497 FAX EFFECTIVE 7-�-2010
DATE I'L �� 2�! U YOUR E-MAIL ADDcRESS
SITE ADDRESS � rC. � �-Gr� /��� , v' G`
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY NAME: I, �GS'�'
OWNER/ ADDRESS: (�� IZ.�d C� C� ��/�. ` CITY �'� � �'�
TENANT
PHONE:�( �— S D Z'j'Zi 2�
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
COMPANY NAME: /��
CONTACT PERSON: M_) 1�
Received By:Pr f�
Dat��e�cW +��
STA
STATE L[CENSE # EXP DATE
ADDRESS: �-+t S dS �/LD SS'�'C�IN+'V� V� �,1� l� CITY N�i� �-�° � STAT�j'`'� ZIPS���
PHONE 7G�_ �I 3� �� U�% FAX
FAMlLY O TWO FAMILY
TYPE,OF WORK: f � NEW �REPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �, �C %� I�' L� F_✓/uuA �� �" ��C—
FEES ARE SASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBE (l��CH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANLIAL J 2006 ASHRAE HANDBOOK. ��\ r j' CjC� d L�U � `
Equipment Installed MFG: MODEL. V li � �b S1ZE/B7'U
MFG: ��� a MODEL: SiZE/BTU
MFG: MODEL: - 5���
A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGF✓OVEN $10.00
,AIR TO AIR EXCHANGEER $15 �FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY L[NER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 _GAS PIPING $10.00 �V ENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge tha the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of dley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a�m;K and wo ls not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work whi 're,quires ev' and approval of plans.
SIGNATURE OF APPLICAN'fi-/ PR[NT NAME� ���L \/nt�'1 /Cirl�jATE L` Z Z / V
APPROVAL
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977