P - 84356Building MECHANICAL Permit No.: fi(S �``7R
Inspections RESIDENTIAL APPLICATION Received By:-�
763-572-3604 CITY OF FRIDLEY ��� � ����
763-502-4977 FAX EFFECTIVE i-i-zo�z
DATE I C} ^ I F� ° i Z- YOUR E-MAIL ADDRESS
sITE aDDttESS rj h R F� f,J � s'T � a,� c.,c- . c� �, �� s S
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
❑ OWNER C�2UNTRACTOR
ADDRESS: rj�,�h WGS't' �r,..u��cc:��"�
PHONE: "](Z,�-LZ�'gCR(o ��5'S
COMPANY NAME:� S � � � ,-��- � \ �-I � .:,�'� � � � a A .r
CONTACT PERSON:
STATE LICENSE #
EXP DATE
ATELI�ZIP 5 .0�-
ADDRESS: t$ � S �- ��\ S Sz - S u�� � � CITY � t,, ,� �. �.� ��STATEM^� ZIPSS�{(� �
PHONE � f 2°% Zti � l�_�l � FAX
�GLE FAMILY ❑ TWO FAM[LY
❑ NEW �I,ACEMENT
❑ TOWNIIOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �►L� �� � �,,� n�<< Cr��-.�r 5 Ff c Z t} o"z U SV �v
�� e C) C? C.:) L7 � J�� ' �1_ () � ti- �t... �_. (� Cct C C c � r ����52 �',�c.� Z. G`� O 7
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: r�-� r MODEL: .SRL1`/� C7�ZO SIZEBTU �� d C�
MFG: (� wrr� trt MODEL: 3,g1`I1itiZOL�E SIZEBTU 2.� oo�/
MFG: MODEL: SiZEBTU
�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 $]0.00
_BOILER $35.00 �GFURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $]0.00 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 buildi ermit and I ckn ledge that the information above is complete and accurate; that the wark will be in
conformance with the ordir�anc s and co of t e City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an ap�li ti r erm' nd work is not t4. start without a permit; that the work will be in accordance with the
approved plan in the case of a� i orl�v re,� res revie approval of plans.
/ Df .-� i
SIGNATURE OF APPLICANT `
APPROVALINSPECTORS
PRINT N
DATE ��2
City of Fridley
/ Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
Te lU� \�`cZ..