P - 41770Building
Inspections
763-572-3604
763-502-4977 FA
DATE � /
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
NA
AD
PHONE:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRI�LEY
EFFECTIVE 7-1-2010
❑ OWNER
��U�
CtTY
Permit No.;
Received By:
�. .,� ,s
STATE_Z1P
COMPANYNAME:�'V. 1'7C/\I IIV�.1 �l /11R IIVV.
CONTACT PERSON:
STATE LICENSE # � P DATE
ADDRESS: _ CITY STATE ZIP
PHONE
FAX
PERMIT TYPE I�INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
'' � TYPE OF WORK: I� NEW �PLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH B OW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 006 E HANDBOOK. > ��jU
Equipment Installed MFG: ��� MODEL: ��� v[/V C'i�q�SIZE/BTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $I5.00 GAS RANGElOVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 �NEW GAS GRILL $10.00
BOILER $35.00 `,�'URNACE $35.00 ,GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $]0.00 POOL HEATER $35.00
DUCT WORK $10.00 _GAS PIPING $10.00 _VENTILATOR $I5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN�I'IL 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 oP"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 case of all w rk w re uires re ew and approval of plan . `
SIGNATURE OF APPL.ICANT � `�O'�U� � PRINT NAMP , � �- r `� DATE � / / I
APPROVAL
DA
V City of Fridley '
,Building:�Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977