P - 42238Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �/ I b� � ( �
SITE ADDRESS 3� �
THIS APPLICANT IS:
PROPERTY �
OWNER/
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
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YOUR E-MAIL ADDRESS
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O� ❑CONTRACTOR
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Permit No ��% � � �} � �
Received By:�������
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CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSQN:
YOUR STATE STATE LICENSE �! EXP DATE
LICENSE WITH qDDRESS: CITY STATE ZII'
APPLICATION pHONE FAX
PERMIT TYPE
TYPE OF WORK:
6�SINGLE FAMILY O TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
�AL,TERATION/REMODEL
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUA J 2I�006 A�RAE HANDBOOK.
Equipment Instatled MFG: A �� MODEL: 5�� � SIZE/BTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZE/BTU
_A/C $25.00 �IREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIIt TO AIR EXCHANGEER $15 FIREPLACE (WOOD) 535.00 NEW GAS GRILL 510.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
_CHIIvIIdEY 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-NdT 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 applicati o a p it work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of work , Yyic quir review and approval of plan �..-- ,
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SIGNATURE OF APPLICAN PRINT NAME�� �J u� � DATE O l� Z���
APPROVAL INSPECTORS SIGNATURE
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridiey, MN 55432
763-572-3604 FAX: 763-502-4977.