P - 48645Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `"7i1 I YJ �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
❑ OWNER
ADD�ss: +�w�
PHONE: � 1 �� "'
CONTRACTOR � COMPANY NAME:
Permit No
Received By:
CITY OF FRIDLEY Dat��d�
EFFECTIVE 1-1-2012
_ YOUR E-MAIL ADDRESS �,�(�C�_(.�i,� ��(�T"�7I�IfY1��1('
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�ONTRACTOR
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SUBMIT A COPY OF CONTACT PERSON: �YY'l((�..YiC�Q V "
YOUR STATE STATE LICENSE # LDq Q�" �ZI GI EXP DATE �Y
LICENSE WITH ADDRESS: ��J � 2 QIACLYY� i\v'L N� CITY� �YV�,1C, t'. l STATEI`�1�\V�IP�%�
APPLICATION pHONE�� ��I�JZ-� FAX ����� �Q?J�
PERMIT TYPE
TYPE OF WORK:
�NGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
�ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (IN�ATE TOTAL NUMBER OF EACH B�9�W)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK. r
Equipment Installed MFG: C K7�It.YY1(�..'� MODEL: SIZEBTU �
A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
�FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
Number of fvctures`@ $15.00 x $15.U0 =
Number of fixtures @ $25.t?� x $25
Number of fixtures @ $35.00 x $35
State Surcharge =
(MINIMUM FEE $40.00) Total -_ $ �
i d°/
SIZEBTU
SIZEBTU
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 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 far 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 work which requires review anc�pproval of plans.
SIGNATURE OF
APPROV
TURE
DATE
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
DATE 3 I I�a� IZ