P - 48674Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADD SS
THIS APPLICANT 1S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
MECHAN�CAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL DDR1
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❑ OWNER �CONTRACTOR �
NAME: ��,� ..a..it/S,�✓
ADDRES :� �1�. ��
PHONE: •
COMPANY NAME:
CONTACTPERSON•
STATE LICENSE #
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PHONE UJ► •
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEW G�REPLACEMENT
1
FAX
,
CITY
Permit No.:
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, �
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.
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DATE
� �TfY ��YL STATE�tP,
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❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK J\ 1!)L�-� �� GL.] ('o� -_--_
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU J 2006 ASH E HANDBOOK ,.�/�
Equipment Installed MFG: ���-.:�L'�' MODEL: �,��VO4 �' SIZFJBN
MFG:
MODEL:
MFG: MODEI,: _
A/C $25.00 FIREPLACE (GAS) $15.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00
_BOILER $35.00 _FURNACE 535.00
CHID�tEY LINER S 10.00 GAS DRYER $] 0.00
DUCT WORK 510.00 GAS PIPING $10.00
SIZEBTU
SIZEJBTU
_GAS RANGE/OVEN $10.00
NEW GAS GRII.L $10.00
GAS LRJIT HTR S 10.00
POOL HEATER 535.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTtL 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 des of the of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applica.tion for a rmit work is not to start without a permit; that the work will be in accordance with the
approved plan in the case o all w rk whic 'r s review and approval of plans.
SIGNATURE OF APPLICANT PRINT NA �"' A'� '
APPROVAL INSPECTORS SIGNAT _ _ DA7� • �
City of Fridley
uilding Inspections Department
31 University Avenue NE, Fridley, IvIN 55432
763-572-3604 FAX: 763-502-4977