P - 44986Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I �/ IO/!�
SITE ADDRESS ,�8�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
r -���,�7
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
❑ OWNER f�CsONTRACTOR
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NAME: `]�N '1' �.O Y\Y�L(,', � �Y'YIOIYdt+1
ADDRESS: (p3� 5i u�r�l-s t�.r�_�,. c�� f'"ri C��t�.lw STA
rHO�E: 7lo a—�.a $ � u aCZ_
COMPANY NAME:�
CONTACT PERSON:
STATE I.ICENSE # EXP DATE
ADDRESS: (�r-�� $ LQ•Kl�.I Q�/�Y�. �i (/tiL� AJ_ _ CITY ^ STATEAI) ZIP���
PHONE 7�,��5 3!� -" C�ia� � FAX ���35- 5�.�' e" 6�oZ i
SINGLE FAMILY ❑ TWO FAMILY
a NEW (}��PLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
O ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXT[JRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK. L,��r,. `�'
Equipment Iestalled MFG: � MODEL: ,�{--� D(�.l7 SIZEBTU %Q �
MFG: MODEL: �(�� SIZEBTU t+v°
MFG: MODEL:
!�A/C $25.00 FIREPLACE (GAS) $15.00
`AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
_BOILER $35.00 �/FURNACE $35.00
_CHIMNEY LINER 510.00 _GAS DRYER $10.00
DUCT WORK $]0.00 GAS PIPING $10.00
SIZE/BTU
_CAS RANGE/OVEN $10.00
NEW GAS GRILL 510.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THTS ►S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the i�formation above is complete and accurate; that the work wi11 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 appiication 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 wo c which requires review and approval of plans.
SIGNANRE OF APPLICANT � O/� PRINT NAME IC�/+'y l r�'r'r' H DATE �Z /o �o
APPROVALINSPECTORS SIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-542-4977