P - 44192Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE2-19-09
DATE � L3 �� YOUR E-MAIL ADDRESS �.S "�� G��= f�y' »' �
SITE ADDR SS '3 / Ic'- �� �� � �'���
THIS APPLICANT IS: OWNER 6�DNTRACTOR
PROPERTY
OWNER/
TENANT
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Permit No.:'
Recei�d�:��_
Date Re�c d: �
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CONTRACTOR ColvtPAtvY N.41vtE: a I�� /z. %�r � �"t� �
SUBMIT A COPY OF CONTACT PERSON: ,�/c-t,� �- C�-' tZ 't-- LC2Gu'�L �"�
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YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ppDRESS: �7 D S � t Y j'V1 C r� �� CITY 7�i / STATE��ZIP S'S �
APPLICATION pHONE %(0.3' 7�'"�'� 7 7� � FAX 7�3- ��� a��7
PERMIT TYPE
TYPE OF WORK:
B'SfNGLE FAMILY ❑ TWO FAMILY
❑ NEW E"REPLACEMENT
❑ TOWNHOUSE
0 ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �S �—�!'� �'� �� � E'�� 4��°�c,�' .' zC 1"1'iQ C�2 �
."'FEES ikRE BASED ON $10.00 PER FIXTURE, EXGEPT WHER� 1'�10'FEIf: FI�Tt3RES: (IAIHICA'I'� TUTAL' NEiN1SER�4FAE,fi!��13�1AW) '�:' -
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:�. PROYIDE HE,hT LUSS CAL�'S PER MA�IUAL 2 06 A HRAE�HAND��UOI�. : ::
Equipment Installed MFG: " yy� MODEL: SIZE/BTl! �
_A/C �25.00
_AIR TO AIR EXCHANGEER $15
_BOILER $35.00
CHIMNEY LINER $10:00
DUCT WORK $10:00
MFG:
MODEL:
S1ZE/BTU
MFG: MODEL: SIZEBTU
FIREPLACE (GAS) $I5.00 _GAS RANGE/OVEN $t0:00 " `
FIREPLACE (WC)OD) $35.00 ' . _NEW GAS GWLL $1Q.QQ -,
�/FURNACE $35:00 _GAS UN1TH'f'R $10.{)0�
_GAS DRYER $10.00 _POOL HEATER $35.06
_GAS PIPING $10.00 _VENTILATOR $t5A0
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 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 all k which requ,tres review and approval of plans. < .
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SIGNATURE OF APPLICANT Z'C �y� PRINT NAME ��Z �i )r�'hC- ��%r �� � DATE �� %� �
APPROVAL INSPECTORS SIGNATURE DATE . _
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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