P - 46815Building
Inspections
763-572-3604
763-502-4977 FAX
DATE��,
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011 �
YOUR E-MAIL ADDRESS
�—
�San �Ur / 1 G
•-�OWNER ❑CONTRACTOR
NAME: `I )b'kiFC V'�V'��1�c
ADDRESS: .SgG�� � y� � �$ttyl�t� Y�� CITY
PHONE: %L � JTO� �t5'� `�
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE # EXP DATE _
ADDRESS: CITY
PHONE FAX
PERMIT TYPE *� ,INGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: /�'"�EW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
�
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
Permit No.:�
Received By:
Date Rec'd:
STA
Z[P
ATE ZIP,
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER 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) $15.00 GAS RANGE/OVEN $10.00
AIR TO A1R EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 _GAS PIPING $10.00 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 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 work h'ch r quires review and�pproval of plans.
� J� .3 %
f 1-
SIGNATURE OF APPLICAN`� , PRI T NANj�C. U� L'� M� �.I�fJG DATE �
G . �A,
APPROVAL INSPECTORS SIGNATURE � '�/�aZ<: DATE / � , � ��
/ City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977