P - 62706Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
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Permit No.:
Received By:
Date Rec'd: A �
DATE YOUR E-MAIL ADDRES S�� r T' C% I� G7 d?"✓�'r �+'• C v �"�
SITE ADDRESS � ���U ✓Z ���- S � • 'V �
THIS APPLICANT IS: ,�WNER �CONTRACTOR
PROPERTY NAr,�: .� �l o��� t.,�•%�"
TNANT ADDRESS: �'I 7 2 .Z�12 S� •�G� CITY �r� �' ��S/ STATEMI� ZIP�I
PHONE: ru � 2-�C/CJ -� S o'' �'
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #_
ADDRESS:
PHONE
PERMIT TYPE � SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK• � NEW ❑ REPLACEMENT
DETAQILED DESCRIPTION OF WORK Ke �b
Ci f� ��✓1 C3 G► V' ir t,° ��l if W� uJ �tG �'t
EXP DATE
CITY STATE ZIP,
FAX
❑ TOWNHOUSE
�ALTERATION/REMODEL
� r./ i h/�G 15.� �L �sl�� � 1
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: SIZEBTU
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 _FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $ I S FIREPLACE (WOOD) $35.00
�BOILER $35.00 =FURNACE $35.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00
DUCT WORK $10.00 GAS PIPING $10.00
SIZE/BN
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS tJNIT HTR $10.00
_POOL ATER $35.00
LATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 application for a permit and work is not to start without a permit; that the work will be in accordance with the
appmved plan in the case of all w' h uire v w and approval of plans.
SIGNATURE OF APPLICANT � � PRINT NAME �'°� ���� N���� DATE /� I C—e�%I �
APPROVAL
' City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977