P - 39644Building
Inspections
763-572-3604
763-502-4977 FAX
DATE� �] / I
SITE ADDRESS ___Gj��
THIS APPLICANT IS:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
PROPERTY NAME:
OWNER/ ADDRESS:
TENANT
PHONE:
Permit No.:
Received By:
Date Rec'd:
YOUR E-MAIL ADDRESS .,,)C?E�- .... N�irr Y�(,t.Jl>C�S �C.� /i�t��� (�,�y�
CITY
ATE ZIP
CONTRACTOR COMPANY NAME: �.�vo '1 r/(.L/O[XJ' S Y�GI61�� i✓� �Q �'
SUBMIT A COPY OF CONTACT PERSON: �S �_ (�Cpj f'�I_���
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: � � �� �� �' � CITY �-( ��� ��Q}'� STATE YIII7�IP,�,�%
APPLICATION pHONE (f�(�- `�.�c_�, i���r FAX
PERMiT TYPE
TYPE OF WORK:
DETAILED
�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW l$ REPLACEMENT
OF WORK
❑ 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 2 06 ASHRAE HANDBOOK.
Equipment [nstalled MFG: CtT� MODEL: SIZE/BTU
MFG: ��'il MODEL: SIZE/B`fU
�A/C $25.00
AIR TO AIR EXCHANGEER $15
_BOILER $35.00
CHIMNEY LINER $10.00
! DUCT WORK $10.00
MFG: MODEL:
FIREPLACE (GAS) $15.00
FtREPLACE (WOOD) $35.00
�FURNACE $35.00
_ GASDRYER$10.00
SIZE/BTU
GAS RANGE/OVEN $10.00
_NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
POOL HEATER $35.00
�V ENTI LATOR $15.00
THIS IS AN APPL[CATtON FOR A PERMIT-NO'T 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 all work which r u�res review and approval of plans.
SIGNATUREOFAPPLICANT�.���� PRINTNAME�f:lC� ���i%b`V�l{.�,� IDATE � � f ��
AL INSPECTORS SI(�NATURE
DATE
`J City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, NIN 55432
763-572-3604 FAX: 763-502-4977