P - 35751Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �'02 7 ' �(
SITE ADDRESS ��Q 3�
THIS APPLICANT IS:
PROPERTY NAME:
OWNER/ pDDRES
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-20] 1
❑ OWNER
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #
PHONE
YOUR E-MAIL ADDRESS
'S e �dC'�,` VC. �R;t,
�iCONTRACTOR
� / !�l n rrcS'c� � ct� l�Ri
457-539�i
,r �- � - • - -
PERMIT TYPE � SINGLE FAMILY O TWO FAMtLY
TYPE OF WORK: � NEW � REPGACEMENT
DETAILED DESCRIPTION OF WORK
FAX
Permit No.:
Received By:�
Date Rec'd: ���� ( �
TE Z[P
EXPDATE
y� CITY_ ���G%/ZP S7ATEL1%�!LIPS.S�3�/
❑ TOWNHOUSE
❑ ALTERATIONiREMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL IVUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $I5.00 GAS RANGE/OVEN $10.00
_A1R TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
MNEY LINER $10.00 GAS DRYER $ I 0.00 POOL HEATER $35.00
UCT WORK $] 0.00 _GAS PIPING $10.00 �/GENTILATOR $ I 5.00
THIS [S AN APPLICATfON FOR A PERMIT-NOT VAL[D 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 application for a per ' and r 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 req es evi and approval of plans.
SIGNATURE OF APPLICANT .�'�� �i'" i�' PRINT NAME ��`1/T � ,^� I% Cy ATE_ �°�� ��
APPROVAL INSPECTORS SIGNATURE ( iL'i,GL�"�"'� DATE `��� �
�- � l��' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432 �� ��
763-572-3604 FAX: 763-502-4977