P - 48308Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE 1-1-2012
DATE Ot "�'�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
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Permit No.:
Received By:
Date Rec'd:O�° �
YOUR E-MAIL ADDRESS �N I'� / V A /=� //Q /� �� � /w 9 'L�/✓N
❑ OWNER �CONTRACTOR
ADDRESS: CITY STATE ZIP
PHONE:
COMPANY NAME: NMO✓ 4r �)t✓C /'( Cb �i � rt�G+✓� L►L G
CONTACT PERSON: '
STATE LICENSE # M :���v EXP DATE
ADDRESS: ST%0 I'f �t � `'� %V � CITY R M�?r�STATE��LIP�
PHONE iC /� '
PERMIT TYPE I �SINGLE FAMILY
O y � 7 FAX
❑ TWO FAMILY
TYPE OF WORK' � NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK � F�► Aw+
❑ TOWNHOUSE
�I ALTERATION/REMODEL
FEES ARE BASED ON 510.00 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: SIZF/BTU
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 _FIREPLACE (GAS) $15.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00
BOILER $35.00 FURNACE $35.00
_CHIIvINEY LINER $10.00 _GAS DRYER $10.00
DUCT WORK $10.00 GAS PIPING 510.00
SIZEJBTU
SIZF/BTU
GAS RANGFJOVEN 510.00
NEW GAS GRILL 510.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $I5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 pe ' an work is not to start without a permit; that the work will be in accordance with the
appmved plan in the case of all wor w r quire review and approval of plans. ,
SIGNATURE OF APPLICANT � PRINT NAME �/ �N 'r' DATE d�� T��
APPRnVAi. iNCPF.( TnRC St(tNATiIRE Y �%� % DATECX ���
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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