P - 47728Building MECHANICAL Permit No.:
Inspections RESIDENTIAL APPLICATION Received By: ✓V �
�63-s�2-3604 CITY OF FRIDLEY Date�e�: - l(��
763-502-4977 FAX EFFECTivE �-�-ZO� i
DATE N I YOUR E-MAIL ADDRESS
SITEADDRESS ��F�� l•.k�F i��_�c:-i��, P(:y�
THIS APPLICANT 1S: ❑ OWNER ONTRACTOR
PROPERTY NAME: �r.
TO NANT ADDRESS: �G�r3�� „�i�z�,c,�',;�r CITY �`_� STATE Nw Z[P��a
PHONE:��o � � � S-7� i
CONTRACTOR COMPANYNAME: �"�YCS��R {'�2,s:N- n }-�h;r c
SUBMIT A COPY OF CONTACT PERSON: _�%��.b,,, $c.(,.,ruC�.,.
YOUR STATE STATE LICENSE #_J�'� ��h O EXP DATE
LICENSE WITH ADDRESS: ���b �f�ir�,�i C.�.,c n% CITY �.ui�e,�� STATEv�NZIP �t(3
APPLICATION pHONE (�S l(�� S�� c+'-� �- FAX
PERMIT TYPE ��NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
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TYPE OF WORK: �W � REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK '�o�SF-c,�1 �.�� 5 '��✓'t�l(cu. �„! � � G�s `�n.c_ _
FEES ARE BASED ON $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.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: t"W�'V' n�(�O_ MODEL: CS�b C-�'`��O SIZEBTU �% �
MFG: MODEL: SIZE/BTU
A/C $25.00 �FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR 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 V ENTI LATOR $15.00
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THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D LINTIL 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 appli on for a permit ar��1 work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of a k whic quires review and approval of plans.
SIGNATURE OF APPLICANT 7 PRINT NAME PC�k I`lr-�`��4 DATE `� �
APPROVALINSPECTORSSIGNATURE DATE
��'��-� . '. ,. .. � =... .... . '. .. . . . � _ ...... .. :i.. , . _ F �� B , � `�r '����7'�.���� .��� �� � , y�`t?�������,��`�, ,
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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