P - 48160Building
Inspections
763-572-3604
763-502-4977 FAX
DA� I �' I
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY N�:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
OWNER
YOUR E-MAIL ADDRE S
t'�/ l.v�� 1► 2 �
Permit No.:
Date1���y.� Y' � �
. �A� � 2 ��,
ENA T ADDRESS: Z S ��, {�' �-t �,4 �Y CITY �2 r � 1.�� Y STATE�LIP SSy 3
PHONE:�63 S�-/ 6ZI �
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH qDDRESS: CITY STATE ZIP
APPLICATTON pHONE FAX
PERMIT TYPE �� SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK ,G
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Fyuipment Installed MFG: MODEL: SIZF/BN
_A/C $25.00
_AIR TO AIR EXCHANGEER $15
_BOILER $35.00
CHIMNEY LINER $]0.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GA5) $I5.00
_FIREPLACE (WOOD) $35.00
_FURNACE $35.00
_GAS DRYER $10.00
GAS PIPING $10.00
StZFJBTU
SIZFJBN
_GAS RANGE/OVEN $10.00
NEW GAS GRILL 510.00
_GAS iJNIT HTR 510.00
, .POOL HEATER $35.W
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 tt�e City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit ork is not to start without a permit; that the work will be in accordance with the
appmved plan in the case of all work ic •eq 'res r iew a approval of plans. ,
SIGNATURE OF APPLICANT 1/� • ° PRINT NAME � DATE �` I/"� v� Z
SIGNATURE
/--�9-
/`—� City of Fridley
ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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