P - 35262�3,uilding
Inspections
763-572-3604
763-502-4977 FAX
DATE I — �� .•
SITE ADDRESS I . J1 ]
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WIT'H
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-t-2011
YOUR E-MAIL ADDRESS
{- �.
❑ OWNER ONTRACTOR
NAME:
ADDRESS: r — � l.n) CITY
1.
PHONE� � ;�) —D�
COMPANY NAME: n ei-
CONTACT PBRSON: 1' �y/�A w Q d. .�1 _
Permit No.:
Received By:
Date Rec'd:
STATE LICENSE # �.1�(� V EXP�ATE
ADDRESS:�,�r'2� � �'�.�A l'Q k�3�'I CITY � ST
PHONE� �rs�]] ^ �� I '�SeS�T_ FAX ^- �•
'B SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �QEPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�
PROVIDE HEAT LOSS CALC'S PER MANi7AL J 2006 AS��RAE HANDBOOK �[�;�" ��,
Equipment Installed MFG: r�C MODEL: ����-a-�--`��\`') SiZEBTU�-�
MFG: MODEL: SIZ$/BTU
MFG: MODEL: SIZEBTU
�A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
ATR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 FURNACE $35.00 _GAS UNIT HTR $10.00
CHI1vINEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTII.ATOR $15.00
Number of;fixtures @ $1Q.00 ` x $10.00 = $ .
Number of fixtures @ $15:00 x $15:00 = $ '
Nuinber of fixtures @ $25.00 � x $25.00 = $�. �
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ 5.00
(MINIMiJM FEE 540.00) Tota1= $ �� � _
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge thax the information above is complete and accurate; that the work will be in
conformance with the ordinances an codes of the City of Fridley and with the Minnesota Construction Codes; that I urtderstand this is
not a permit but only an application f a permit and ork is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work wh r uire eview and approval of plans.
SIGNATURE OF APPLICANT Y �i PRINT NAME �"��'� 1)'W 9P/i _��D�TE��
Il�
DA
� City of Fridley
uilding Inspections Department
1 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977