P - 42276Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �`: � ' ; .a' C..°"
SITE ADDRE �
THIS 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 7-1-2010
YOUR E-MAIL ADDRESS
`�/� f✓i;y
OWNER ❑CONTRACTOR
Permit No��/�
Received By:
�
Date Rec'd: Q(/(�
.a�nxESS: 7YZ . 5 ,6� �v , �(,/�, � `. ciTY� ..:r � ; sTATE ��i�z��� 2
PHONE: c5/Z- `��5 � (�<j
COMPANY NAME;
CONTACT PER30N:
STATE LICENSE # EXP DATE
ADDRESS: CITY STATE ZIP
PHONE FAX
Fd SINGLE FAMILY
❑ NEW �
DETAILED DESCRIl'TION OF WORK
� TWO FAMILY
REPLACEMENT
Lc,
❑ TOWNHOUSE
❑ 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 MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZE/BTU
A/C 525.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
,_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
_CHIMNEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 _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 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 al�yo �w}�ch requires review and approval of plans.
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SIGNATURE OF APPLICANT
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APPROVAL INSPECTORS SIGNATURE ;�
DA
—�'' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977.