P - 41803Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ,_� - � � ^ i %
SITE ADDRESS J �o
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
NAME:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-20] 1
❑ OWNER
YOUR E-MAIL ADDRESS
PHONE: % �D 3 ,�� �4 Co�s,�
COMPANY NAME:
CONTACT PERSON:
0
CITY
Permit No.:
Received By: 1�'�'�
Date Rec'd: `�`� �(� � � �
TATE�Z[P�
STATE LICENSE # EXP DATE
ADDRESS: 1�5�� ��� d� CITY rn. (s. STATEI�'��ZIP��g
PHONE?G � — � �� �.7 � FAX
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW '�LEPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK � �„ �/ �,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANii� J 2006 E HANDBOOK. 1�
Equipment Installed MFG:e�S i MODEL: I U�F#1 S1ZE/BTU �
MFG: �� `� MODEL: 1� 3 14 ►.�A SIZE/B?U ,..�, D�..J
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
CHIMNEY LINER $10.00 �AS DRYER $10.00
DUCT WORK $]0.00 GAS PIP[NG $10.00
SIZE/BN
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
POOL HEATER $35.00
�V ENTiLATOR $15.00
AN APPLICATION FOR A PERMIT-NOT 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�ase�- 1 wo_r� ' h qu' es review and approval e€�{�l n�..s�.��
ase-
SIGNATURE OF APPLICANT PRINT NAME l� h^ �1,.L11�d` S DATE �'� I�� 1�
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977