P - 35410Building
Inspections
763-572-3604
763-502-4977 FAX
DATE %'Z�n ���
SITE ADDRESS �yZ%
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
N
MECHANICAL
RESIDENTIAL APPLICATION
Permit No.: ;
Received By:
CITY OF FRIDLEY Date Rec'd: �.�I l�
EFFECTIVE 1-1-2011
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_ YOUR E-MAIL ADDRESS c�jTf.e% ��� ,L�a_ L�fc s .wr
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❑ OWNER 4$CONTRACTOR
ADDRESS: �y.Z/ %�.�o r' �i', /V� CITY
PHONE:6/�- Z�l'�.�'' %YGC
COMPANY NAME:
CONTACT PERSON:
ATE%/ !�Z[P�Z
STATE LICENSE # EXP DATE
ADDRESS: Z`L 3 SA-,,,,.(� f r� PZ`f CITY ,7o,Vr �C �%�d STATE�NZIP.f�3LZ
PHONE ?!�� ��/ 9 ��� %� FAX
�S SINGLE FAMILY ❑ TWO FAMILY
0 NEW i� REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
L
FEES ARE BASED OlV $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
EquipmentInstalled MFG: Qvys� MODEL: Qls�/yQ�fi/.S£S SIZE/BTU 0��
MEG: �Gyf/ � MODEL: L(./}'PiY OZ�%�'/ f Z SIZE/BTU Z^ f a.v
MFG: MODEL: SIZE/BTU
A/C $25.00 REPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 �REPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 �FURNACE $35.00 GAS UNIT HTR $ I0.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK$lO.OQ _ _GAS f'IPiNG $10.00 V£NTILATOR$15.00
THIS IS AN APPLICAT[ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 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 applic ' or a ermit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case o 1 wor hic quir and approval of plans.
SIGNATUREOFAPPLICANT,_ I/z��� PRINTNAME �GNif-/N �«.f'�ATE %"Z� P%�
AL INSPECTORS SIGNATURE
DA
" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977