P - 43885Building
Inspections
763-572-3604
763-502-4977 F.AX
DATE ( �
SITE .�DRESS _
TI-IIS ?.PPLIC.aNT IS
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ O�l'NER
PROPERTY N.�,�:
OWNER/ :aDDRESS:
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERNIIT TYPE
TYPE OF WORK:
�
COAIPANY N.�1I�4E: v�an..a�.. � ��,a.���y .,. . ... .......,....,... ..
CONT�.CT PERSON: ym0
STATE LICENSE 1# F 17_R7d_7� DATE
ADDRESS:
PHONE
F?.h-IILl' ❑ T�L'O F_�-III,Y
❑ NE�L' �REPLACE1�fENT
.
DETAILED DESCRIPTION OF WORK
CITl'
FAX
❑ TORjNHOUSE
❑ ALTEItATION%REMUDEL
Permit No.:� � �%�'��
Recei�-ed Bv:�� ]l�'� r
� -�-
D���� ���.---�� �
STATE ZIP.
FEES ARE BASED ON $10,00 PER FIXTLTRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBF1t OF EACH BELOVi7
Equipment L�afatled MFG: MODEL: SIZFJBTU
MFG• �'� MODEL. � SIZE/BTU `�' J �
�( MFG:: Q�YYY MODEL: � SIZEBN
!lA/C 525.00 PLACE ( AS) $15_00 GAS RANGF/OVEN 510.00
_AIIt TO AIIZ EXCFIANGEER $15 PLACE (WOOD) $35.00 _NEW GAS GRII,L 510.00
BOII.ER 535.00 �FURNACE 535.00 GAS IJNIT HTR $10.00
_CFIA�tEY LINER 520.00 GAS DRYER �10.00 POOL HEATER �i5.00
lDUCT V✓ORK $10.00 _GAS PIPING S 10.00 VENTILATOR 515.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID IINI'II, PROCESSED
I hereb�� apply for a building p it and I acicno���ledge that the information above is complete and accurate; that the «-ork �vill be in
conformance �vith the or ' an d codes Citv of Fridiey and �t-ith the Minnesota Construction Codes: that I understand this is
not a perniit but onl}' app � a� f r pe iit an work is not to start i��ith t a perniit; that the wo - ��-ill be in acco ance t�ith the
approved plan in th ase of 1 ch equires eview and approval of p . �
SIGNAiURE OF AP I_ NT TI.�.¢
- City of Fridley
�Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977