P - 35472Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / �_
-•-r�-
SITE ADDRESS _
�us �PLic. arrr [s:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFF'ECT[VE 3-19-09
n
� PROPERTY N:�,¢:
OWNER/ �DDRESS:
TENANT
�orrE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERNIIT TYPE
TYPE OF WORK:
YOUR
��
CObQ�ANY N.�fE: •��a� wa� �+ � �caan �y .,. ... .. .............. .-
CONT,�CT PERSON: y
STATE LICENSE # F17_R7d_7E� DA'CE
PHONE
FA14IIL7" ❑ TRrO F.AivLII,l'
❑ NE W �EPLAC'EI�fENT
DETAILED DESCRIPTION OF WORK
CITY
FAX
❑ TO�i'NHOUSE
❑ ALTERATION/REMODEL
--- - ---
Permit No.:
Recei�-ed B�-
I�t����� � �n�n
TE ZIP
FEES ARE BASID ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBIIi OF EACii BELOV1�
Equipment Instalkd MFG: MODEL: STZFJBTU
_ MFG: /Y` MODEL: V�'�.J SIZFJBTU O�
�( MFG: �'�� MODEL: _�C� SIZF/BTU
! �A/C $25.00 ACE (GAS) SI5.00 _GAS RANGE/OVEN 510.00
_AIIt TO AIIZ EXCHANGEER $t5 FIREPLACE (WOODJ $35.0(1 NEW GtLS GRILL 510.00
BOII,ER 535.00 �'URNACE 535.00 GAS IJNTf HTR 510.00
CI�INEY LINER 510.00 ,GAS DRYER 510.00 POOL HEAIER 535.00
DUCT WORK 510.00 GAS PIPING 510.00 VENTILATOR 515.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a building pemiit and I ackno��ledge that the information abo�e is complete and accurate; that the ���ork �vill be in
conformance �rith the ordinaiices and cod ih� of Fridley and �vith the Minnesota Construction Codes; t6at I understand this is
not a perniit but o � at� n for pe it a work is not to start �r•ith t a pernlit; that the �vo - ��=ill be in acco ance w-ith the
approved plan � e case k whic requ� s review and approval of p .
SIGNATURE OF _ C. N �4E / ! �b
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977