P - 84381Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE i-i-ZO�a
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
T YOUR E_-� AIL ADDRESS
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❑ OWNER L�JCUNTRACTOR
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PHONE: ��lj -- �� /��
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COMPANY NAME: � `,T C
CONTACT PERSON: a -rf [ �). /)
STATE LICENSE #
ADDRESS: � � � ,� +"� �
PHONE �� �7 ' �
GLE FAMILY ❑ TWO FAMILY
0 NEW q,R�LACEMENT
DETAILED DESCRIPTION OF WORK
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f"�EXP DATE
CITY � ��
FAX �-�'� .�' �i�% �'/
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
Permit No.
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FEES ARE BASED ON $10.00 PER FIXTURE, EXC PT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUA J 006 A RAE HANDBOOK �
Fquipment Installed MFG: f MODEL: � SIZEBTU
_A/C $25.00
_AIR TO AIR EXCHANGEER $15
_BOILER $35.00
_CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
_FIREPLACE (GAS) $15.00
�FI LACE (WOOD) $35.00
ACE $35.00
_GAS DRYER $10.00
GAS PIPING $10.00
SIZEBTU
SIZEBTU
_GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
_POOL HEATER $35.00
_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 p t d 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 i eq ' es r ew and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME �J C0�2�I/rGNS D,ATE �Q/ �Z�,
APPROVAL INSPECTORS
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977