P - 47739Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ Ie"{7tC'` (
SITE ADDRESS �I �l
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
NAME: G
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PHONE: � � !n j
YOUR E-MAIL ADDRESS V� CC� �
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�ICONTRACTOR
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CIT'Y_ �JZ l t'�� � ,,, STATEm�ZIP
COMPANY NAME: `
CONTACT PERSON:
STATE LICENSE # EXP DATE
ADDRESS: CITY
PHONE�_(p�% — � '�,- STATE�ZIp
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PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEW � �PLACEMENT
DETAILED DESCRII'TIQN OF WORK lj�y
❑ TOWNHOUSE
J�ALTERATION/REMODEL
'_ / ' _ _ � �.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: �
MODEL: ���'" SIZEBTU
MFG: MODEL:
SIZEBTU
�A/C $25.00 MFG: MODEL:
FIREPLACE (GAS) $15.00 SIZEBTU
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 GAS RANGE/OVEN $10.00
BOILER $35.00 FURNACE $35.00 _NEW GAS GffiLL $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 GAS UNIT HTR $10.00
DUCT WORK $10.00 GAS PIPING $10.00 _POOL HEATER $35.00
Number of fixtures @ $10.00 x $10.00 = $ —��TILATOR $1 s.00
Nurnber of fixtures @ $15.00 x $15.00 = $
Number of fi}ctures @ $25.00 � x $25.00 = $� • � a
Number of fi�ctures @ $35.00 x $35.00 = $
State Surcharge = $__5 00
INIMUM FEE $40.09 Total = $ "L �./ � ��
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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
approved plan in the case o ork which re uires review and approval of pl s.
SIGNATURE OF APPLI AN
PRINT NAME DATE �
APPROVAL INSPECTO ATURE
PLEASE NOTE: SEPARATE pERMITS qRE RE LJJRED FOR BUII,DING ELECTRICAL AND MECHAI�TICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977