PERMIT - 35051Building
Inspections
763-572-3604
763-502-4977 FAX
DATE f — � � -'- �
SiTE ADDRESS _�
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
, __ ,YOUR E-MAIL ADDRESS
❑ OWNER
NAME:y
ADDRESS:
COMPANY NAME: B
CONTACTPERSON:
STATE LICENSE # �
ADDRESS: 23�
PHONE � S_L"-
❑ SINGLE FAMILY
1��(/
��
lG�i�fC,� �
i�
� I � FAX
[�TWO FAMILY
r
TYPE OF WORK: � NEw 6�REPLACEMENT
�'
DETAI�,ED DESCRIPTION OF WORK � I
�,.�ryl �G�_
Permit No.:L
Received By:
�����
ATE /�NZIP��
EXP DATE J�-'� - l I
_ �r CITY �'��i S STATE[�l ✓ZIP.
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
.o�, bti s� �� � ;'r- ,�.� �C r�n l4 �.
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,�200�6�ASHRAE HANDBOOK. �a � �
Equipment [nstalled MFG: � MODEL: / SU��L�I �� SIZE/BTU v
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $I5.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 �GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK$]0.00 _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 applic tion for a rmit 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 whic requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME��%C- � Xf�'1 SS'P/� DATE I���� I I
APPROVALINSPECTORSS G ATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977