P - 39357�
Building
Inspections
763-572-3604
763-502-4977 FAX
Dn�_y -- a- - /
SITE ADDRESS _
THIS APPLICANT 1S:
PROPERTY
OWNERI
��`
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFF.('TIYE i-1-20ll
❑ OWNER i',�CbN'
r�
NAME: �c't . I"�
Anv�ss: S7 9 i
Du�,.«. /� C�� ,S'9 2 _
E-MAIL
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Permit No.: G-� 1 I'�� '-
Received B�':� � �
D��'��:y "
� �/a/ �� o � c�-.�cK•�, e
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sTn� u����'�
CONT'RACTOR COMPANYNAME: � e!-G� � %G /
SUBMIT A COPY OF CONTACT PERSON: �
YOUR STATE STATE LICENSE # � 2. 7�- NI C� EXP DATE �— L-��-
LICENSE WITH .�D�SS: ,�� ��X ��� �T ��-� �%,2 �.�� STA� Z�p ��a
ArrLicATTON rxor� �'Z-yyo- (� � .2 �{ F.�ac �Sa-- ��D, (QS�� ,�
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY O TOWN}IOUSE
TYPE OF WORK• � NEW � REPLACEMENT ❑ ALTERAT'[ON/RF.MODEL
DETAILED DESC ION /O�F WORK
� Q O� �(� i`h � �.
0
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NOMBER OF EACH BELOR�
PROVIDE HEAT LOSS CALC'S PER MANUAL d 2006 AS[IRAE HANDBOOK
Fquipment Installed MFG: ,Q/w,�A�� MODEL: /t l SIZF1B1i7 l�
C: 'v
MFG:
MODII.:
MFG: MODEL,:
A/C $25.00 FIREPLACE (GA5) 515.00
AIR TO AIIL EXCHANGEER $IS FIREPLACE (WOOD) S35_00
�BOILER $35.00 FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER 510.00
DUCT WORK $10.00 GAS PIPING SI0.00
Number of fi�ciw+es @ S 10.t10 x$10.00 = S
Number of fixtures @$15.00 x$15.00 = S
Number of fi�ctures (c�r $25.0(! x$25.00 = S
Number of fixtures @ $35.Q0 � x $35.OQ = $ �, �
EY��L� lfJ
SIZF/BTU
GAS RANGFIOVEN SI0.00
NEW GAS GItILL 510.00
GAS UNIT H1R S IO_00
POOL HEATER 535.00
VENTILATOR SiS.00
State Surcharge = S 5.00
(MINIMiTM FEE $40 00) Tota1= $ '�� , a D
THIS IS AN APPLICATION FOR A PERMIT-NOT VAI.ID UN1TI. PROCFSSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; thaY the work will be in
cflnformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I undeistand this is
not a permit but only an application for a permit and work is not to start without a permit; the work wil( be in accordance with the
approved plan in the case of a(1 work which requires 'ew and approval of plans.
SIGNA"['CJRE OF APPLICAN'I' �O/"'D (' PRINT NAME DATE /'� �
APPROVAL INSPECTORS SIGNAT[JR]
PLEASE NOTE: SEPARATE
DA
City of Fridley
B ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
AND MECHANICAL WORK