P - 42184Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
ARPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS �\ 1'1C�
1v �
O OWNER �ONTRA(
NAME: �Cil.1'i IV'�i���
ADDRESS:_ 1�(p �p3�
PHONE: � (p '� ~ S Dr� ° 7
COMPANY NAME:'L�Y'�� �'
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CONTACT PERSON: " �''
STATE LICENSE # L� 5$ �`7 S i'�I�7 EXP DATE M 1 I
ADDFZESS_�OJ`'���O�V'l�f��� �V� CITY �
PHONE �OS I—• o�g -'� a7 i FAx (05 �� a�l - d�v� $ _
PERMIT TYPE �INGLE FAMILY O TWO FAMILY
TYPE OF WORK: � NEW �REPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
AT��ZIP
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE iYOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU J 2006�SHRAE HANDBOOK, �T
Equipment Installed MFG: � MODEL� m���A � SIZEIBTU �
1.1
A/C S2S.00
AIR TQ 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
SIZEBTU
SIZE/BTU
GAS RANGE/OVEN 510.00
NEW GAS GRILL 510.00 (
GAS UNIT HTR $10.00 �� `
�POOL HEATER $35.00
VENTILATOR $i S.OQ
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 camplete 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 wark is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all wo„rk which r�ires review and approval of plans.
SIGNATURE OF APPLICANT
PRINT NAME
DA
City of Fridley
Buil�ling Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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