P - 41407Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE,-�-ZO>>
DATE�1 ` ( `� --
SITE ADDRESS ��
THIS APPLICANT [S:
PROPERTY
OWNER/
TENANT
�� ��
❑ OWNER
ADDRE/SS:�;Z
PHONL� �� ,-
YOUR E-MAIL ADDRESS
�.rZ� i �} C ��LC
�CONTRACTOR
G ✓ i {n K:'ti
�, C� � �- l� �
/ / r--
y��i!^+ "" �i(!',--� _`_J
CONTRACTOR COMPANY NAME:� , �
SUBMIT A COPY OF CONTACT PERSON: )� ► r �
YOUR STATE STATE LICENSE #
LICENSE WITH ADDRESS:� % � •{� I � � �
APPLICATION
PH� --
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEw �EpLACEMENT
_ �
DE•TAILED DESCRIPTION OF WORK
.,� ti L 1,�..
EXP
=� IL
FAX
Permit No.: ' "' L�
Received By: ��
������� ".--�-�
_.�_. � 7 rL�� i�.-) � �
_ 1�/C. � � '�C..L f/ �. STA
-n,�' � � I-1�� ��
�ITY -�'iZj {�, \ STAT�ZI��
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU L J 2006 ASHRAE ANDBOOK. ��}
Equipment Installed MFG �,�:�-�� � MODEL��� - p73 (G SfZE/BTU �" �� .�
MFG:LZ,_/�/� l'�iK �+�^�"�r,�.CiL MODELJS�j'^,Q7Q ✓'�S� /E BTU C� Q dQ
A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE {WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZE/B7'U
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
TH1S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 ap�lication 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 o�f � work whic r uires review and approval of�p ans.
t �
SIGNATURE OF APPLICANT - ` �' ,C1yti�^�y'—PKINT NAME' ��C' Z ������'/t-� DATE �`�/ l ` /�
,�
APPROVAL INSPECTORS SIGNA'1` RE DAT
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977