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P - 44976Building MECHANICAL Inspections RESIDENTIAL APPLICATION �63-s�2-3604 CITY OF FRIDLEY 763-502-4977 FAX EFFECTIVE 1-1-2011 DATE F %'"' � V "I . SI7'E ADDRESS �I THIS APPLICANT IS: PROPERTY OWIVER/ TENANT CONTRACTOR SUBMIT A COPY OF YOUR STATE LICENSE WITH APPLICATION R E-MAIL ADDRESS ❑ OWNER ADDRESS:_ CQ J�+� COMPANY NAME: � CONTACT PERSON: STATE LICENSE # Z d% HLlllCbJJ: "�_7 � ,("�. /�(�lyl. /,J7/ PHONE%� 3 �Gr /,�0� FAX PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY TYPE OF WORK: � NEW ❑ REPLACEMENT DETAILED DESCRIPTION OF WORK IV�.- CIT1'� EXP pATE �CJ� — CITY %�o � �iz Z 4�1.5 ❑ TOWNHOUSE 1L� aLTERATiON/REMODEL Permit No.: Received By: � R�� f Dat��' � � � o � � � A' STAT�.-�� ZIP� �3 FEES ARE BASED ON $10.00 PE12 FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL IVUMBER OF EACH BELOW) PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK Equipment Installed MFG: ,_ _ MODEL: SIZE/BTU MFG: G� MODEL: 17.� SIZE/BTU _�o � 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 $10.00 GAS DRYER $10.00 _DUCT WORK $]0.00 GAS PIPING $10.00 SIZFJBTU GAS RANGE/OVEN $I0.00 NEW GAS GRILL $10.00 GAS UNIT HTR $10.00 POOL HEATER $35.00 _V ENTiLATOR $15.00 THIS 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 Frid(ey 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 approved plan in the case of all w rk � ich �rires �approval of plans. f ,/�j� r SIGNATURE OF APPLICANT o 4!r PRINT NAME �(�� �'���� ~t �� pATE ����� ^// APPROVALINSPECTORSSIGNATURE DATE City of Fridley' Building Inspections Department 6431 University Avenue NE, Fridley, MN 55432 763-572-3604 FAX: 763-502-4977