P - 42366Building MECHANICAL
, � inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX r,..,,.�T.,...� . ��.�
DATE I � �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
Permit No.: � �, �, � C�:
Received By: 4�
Date �� � U � �i � Q
❑ OWNER �CONTRACTOR
NAME: � i� YlA�X�'WY�,i,�� m�,C�� r J
ADDRESS: n CITY STATE ZIP
PHONE: %�(i� � b�(i "1 � [�, �
COMPANY NAME: V�iI� ���� f�A �,� L'� f � I�.h'1 �I i�01 i.LL
CONTACTPERSON:
STATE LICENSE # EXP DATE
ADDRESS: '� � G or V{'. CITY_ �} I i.S1l.�lIS��YIL STATEYYI�ZIP SSNZIv
PHONE O �� FAX �5(x�'��� I %�O�
j�SINGLE FAMILY ❑ TWO FAMILY
V
❑ NEW
OF
❑ TOWNHOUSE
O ALTERATION/REMODEL
0
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOR.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: ����ii Vl �. � MODEL: rc� l"I sw�� I aV ' �� SIZE/BTU c�',0�, ��
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00
BOII,ER $35.00 ✓F'URNACE $35.00
CHIMNEY LINER $] 0.00 GAS DRYER $10.00
_DUCT WORK $10.00 GAS PIPING $10.00
SIZE/BTU
GAS RANGE/OVEN $10.00
_NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
_POOL HEATER $35.00
�' VENTILATOR $15.00
T S IS AN APPL ION FOR A PERMIT-NOT VALID iTNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 al work �av�iich requires review and ap�roval of plans. ,`
� Ct��t�3� � ' ' ���`,
SIGNATURE OF APPLICAN � PRINT NAME DATE � ���
'
APPROVAL INSPECTORS SIGNA RE x °J�i' `5 DATE c�[' �/ �l�
�,��' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977