P - 39655Building
Inspections
763-572-3604
763-502-4977 FAX
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MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] 1
Permit No
Received By:_
Date Rec'd:
DATE �� YOUR E-MAIL ADDRESS �J,,����'t� (�' � jj,'f
SITE ADDRESS ��'L�„�_ 1{, � r°
THIS APPLICANT [S: �OWNER ❑CONTRACTOR
PROPERTY NnNiE: ��A�N���F ,j-�e.� ,c�-c�,.»
OWNER/ ADDRESS: �7�ciZS '�T.. � ST ��' CITY �� I�[,,�`F �; STATE�i ZIP�Z,,
TENANT nur,�r� �, -� � .—'��i9 _GC,i 2�`
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
COMPANY NAME:
CONTACTPERSON:
STATE LICENSE #_
ADDRESS:
PHONE
� SINGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
EXPDATE
CITY
FAX
❑ TOWNHOUSE
I�( ALTERATION/REMODEL
_ , n _ � . ,� �
TATE ZIP
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE IYOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment [nstalled MFG: MODEL: SIZE/BTU
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BO(LER $35.00 FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
DUCT WORK $10.00 GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS�AN APPLICAT[ON FOR A PERMIT-NOT VAL1D 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 of all y�Prk whicl�,�require��iew and approval of plans.
SIGNATURE OF APPLICANT
AL INSPECTORS SIGNATURE
PRINT NAME
DATE
City of Fridley
" ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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