P - 44927Building MECHANICAL Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
�63-s�2-3604 CITY �F FRIDLEY Date Rec'd:
763-502-4977 FAX EFFECrrvE i-�-2o� i
DATE
SITE ADD SS _)
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMI'f A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
p YOUR E-MAIL ADDRESS
�,� IC i VC�'ViCr.J �Cf/�•
❑ OWNER J�CONTRACTOR
NAME:_ C l�prM�.�� w: i�iaM+S
ADDRESS:�Sf'�i /�;V�I'✓1C.•r ��Y'.
PHONE:
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #_
ADDRESS:
PiiONE
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: �NEW O REPLACEMENT
DETAILED DESCRIPTION OF WORK in c� w. I �
%
dba
ATE/�NZIP_S /
�.icense 20512060 - --- .
EXP DATE
CITYRoseville, MN 55113 STATE ZIP
FAX
�
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
� r_e n�k.� c �. /G� s%' •,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. EIXTURES: ((NDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment [nstalled MFG: �tw ��1 Ls( o MODEL: %SD �/Q SIZE/BTU e��,f�?>'�
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
_AIR TO AIR EXCHANGEER $1 S _F3REPLACE (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
SIZE/BTU
S12E/BTU
_GAS RANGElOVEN $10.00
NEW GAS GRILL $10.00
`GAS UNIT HTR $10.00
_POOL HEATER $35.00
. VENTTLATOit $ I5.00
THIS IS AN APPL(CAT[ON FOR A PERMIT-NOT VALID tJNTIL 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 fo rmit 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 r uire view and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME /� Cd� r1 �(�..s b i C DATE � �f
APPROVALINSPECTORSS[GNATURE r l/�� naTF
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-497i