P - 46812Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ( („)/[�/C
S1TE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPI,ICATION
PERMIT TYPE
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECITVE 1-1-201 ]
YOUR E-MAIL ADDRESS
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❑ OWNER
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COMPANY NAME:e
CONTACT PERSON:
CITY
Permit No.:
Received By:
STA
STATE LICENSE # ' EXP DATE
ADDRESS: �. CITY i' STATE � GIP����
PHONE � FAX � ��
TYPE OF WORK: I� NEW
DETAILED DESCRIPTION OF
FAM]LY ❑ TWO FAMILY
❑ 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
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGF,/OVF,N $10.00
AI TO AIR EXCHANGEER $] 5 FIREPLACE (WOOD) $'35.00 _NEW GAS GRII.L $10.00
ILER $35.00 FURNACE $35.00 AS UNIT HTR $10.00
�CHIMNEY LINER $10.00 —GAS DRYER $10.00 �OOL 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 1 understand this is
not a permit but only an application for a permit and wark is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work which requires review and approval of plans. �
SIGNATURE OF APPLICANT � PRIN"3' NAME� AA � _DATE_� ja�
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977