P - 42232Building
Inspections
763-572-3604
763-502-4977 FAX
DATE lp ' C� `O
SITE ADDRESS C���
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
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❑ OWNER jJ�CONTRACTOR
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COMPANY
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TE ZIP.
STATE LICENSE EXP DATE
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ADDRESS: CITY STATE ZIP
PHONE �
`�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ 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 ASIiRAE HANDBOOK.
Equipment Installed � MFG: �_ MODEL: SIZE/BTU
MFG: MODEL: SIZEBTU
IvIFG: MODEL: SIZEBTU
_A/C �25.00 _FIREPLACE (GA5} $15.00 _GAS RANGE/OVEN $10.00
AIIt TO AIR EXCHANGEER $15 _FII2EPLACE (WOOD) $35.00 NEW GAS GRILL �10.00
BOILER $35.00 FURNACE $35.00 GAS LINIT HTR $10.00
_CHINII�IEY 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-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 case of all work w ]r quires review and approval of plans. _
SIGNATURE OF APPLICANT PRINT NAME ►/l Ie � � I DATE_��
APPROVAL INSPECTORS
DATE
,_,M...-�1 City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977.