P - 451011 '
�uilding
�nspections
'763-572-3604
763-502-4977 FAX
DATE UC
SITE ADDR6SS _
THiS APPLICANT IS
PROPERTY
OWNER/
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2010
�--��- YOUR E-MAIL ADDRESS
l.,�- � �- /�/17/y7 /.� I.� {�� .1/1 ,
❑ OWNER
�
CITY
Permit No.:
Received By:! �
Date ���� � �
STATE
PHONE: ,(� " ' /
CONTRACTOR COMPANYNAME: ,�;^ror���� Kr.�,-.,
*. a s .
CONTACT PERSON: r���^N �±;," ��' s't �"Q !°+ � rna. t� a r�.+,�
SUBMIT A COPY OF �----,�J �,T--�.Y.��—., � a� ,�, y
YOUR S1'ATE STATE LICENSE # g'^�,;s`�yr �-; �A g E �,�
} � i� ':T�: � �
LICENSE W1TH ADDRESS: '7'�� .;�C`, �(�yy�^'�[TY STATE ZIP
APPLiCATION
PHONE FAX
PERMIT TYPE SINGLE FAMILY ❑ 7 WO FAMILY ❑?OWNFIOUSE
TYPE OF WORK: � NEw �REPLACEMLNT L] ALTERATION/REMODEL
(/ �
DETAILED DESCRIPTION OF WORK
�� r
G'EES ARE BAS�D ON �10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NC�iVIBER OF EACH BELOW}
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL �( /"� �,YJ�/�-' SIZEBTU����
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $I5.00 GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $ I S FIREVLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 j/ 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 $]0.00 VENTILATOR $15.00
�Ctit�e8- , � �iU.flO' ac �,34.Qi3 - � �' � �� - : �
� j _
"� � �.� . -
u�t_ �ar a �i�, � � � - •. � : , ' � � �, ,;,•, � � � ,
T�ur�b� of fixtuqr�s �,a� $i 5.00 x$iS.�O =$
N�1�r �f €'txtc�tes,� .$2�.{J� - x �2S..�U = �. ` ' .''
Number of �attues @ $35.a� � x $35.(3(3 = $' �' �� -'
' � �J, �:�..
�tate��S�rcharga=$ � ���
M��M�. FLE !�.3�.�i# Tc�ta1='��"'� �� ` C�'�l
THIS IS AN APPLICAl"ION FOR A PERMIT-NOT VALID L'N7"IL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is comptete 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 wor whic equir e'ew an proval of plans ��' ��c � 7, 2���J
� /
SIGNATURE OF APPl]CANT � .�:ti9.%% PR1NT 1�AMF. /J '� / I�.YI ne�rc � /
APPROVAL INSPECTORS SIGNATURE/�� ` �p��i�=v�'-.r.�/ _ DATE ` IY�Z L
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
2