P - 48159Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ,� — f � � (
SITE ADDRESS �
TH1S APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] 1
❑ OWNER
NAME:
ADDRESS: CITY
PHONE:
COMPANY NAME:
CONTACT PERSON:
Permit No.:
Received By:
Date Rec'd:
TATE Z[P.
STATE LICENSE # EXP DA�TE v
ADDRESS: � � CITY /�v�G� STA7`h'�ZiPS_ S��
PHONE �p I - Z.�3 FAX
�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
❑ NEW ❑ REPLACEMENT �+ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK
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 200 ASHRAE HANDBOOK.
Equipmentlnstalled MFG: � t� -�r,„�� MODEL: �_ SIZE/BTU_��'°�_
MFG: � MODEL: S[ZE/BTU
MFG: MODEL:
A/C $25.00 FTREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 �FURNACE $35.00
�C MNEY LINER $10.00 GAS DRYER $10.00
CT WORK $10.00 GAS PIPING $10.00
SIZE/B711
_GAS RANGE/OVEN $10.00
_NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
POOL HEATER $35.00
�VENTILATOR $ I 5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID 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 application for a permit and work is not to start without a permit; that the work wil) be in accordance with the
approved plan in the case of all �ork which re��es review and approval of plans.
SIGNATURE OF APPLICANT
APPROVAL
PRINT N
DA
City of Fridley
��! i l� � DATE � �' I
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977