P - 46264Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS �'��� �
THIS APPLICANT IS:
PROPERTY NAME:
OWNER/ ADDx�
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER
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YOUR E-MAIL ADDRESS
CONTRACTOR COMPANYNAME: ,v��W
SUBMIT A COPY OF CONTACT PERSON: �q�I �X•f 1`N?
YOUR STATE STATE LICENSE # V� ��SS— P�
LICENSE WiTH ADDRESS: �t��� 6,O �f
APPLICATION pHOxE �4S) "o� $ �%—'c�-oZ��
PEBMIT TYPE INGLE FAMILY � TWO FAMILY
TYPE OF WORK: � NEW $ZREPLACEMENT
FAX
Permit No.
Received By:
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�CITY �L �� STAT�ZIA
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EXP DATE � Z L3 L(
�_CITY STATEIY�ZIP
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� TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK ��p� � p�YYI(�A1�(\ ���S�P��' o� .�t"UYl
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FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACA BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU JL� _ 2006�SHRAE HANDBOOK ^��
Equipment Installed MFG: ��F �(� MODEL: � � SIZE/BTU C7�
idA/C $25.00
AIR TO AIA EXCHANGEER $15
BOILER $35.00
CHIMN�Y LINER $10.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
_FIREPLACE (GAS) $15.00
FTREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
�GAS PIPING $10.00
SIZEBTU
SIZEBTU
_GAS RA23GElOVEN $10.00
NEW GAS GRILL $10.00
�GAS UNIT HTR $10.00
�POOL HEATER $35.00
VENTILATOR $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 wiil 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 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 a11 wark which req ires review and approval of plans.
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SIGNATURE OF APPLICANT PRINT NAME � Y�i� ^� ATE I� l
APPROVAL INSPECTORS SIGNATURE I� � DATE ` X I �
City of Fridley
' ding Inspections Department
6431 University Avenue NE, Fridiey, MN 55432
763-572-3604 FAX: 763-502-4977