P - 35060Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE �-,-zo�o
DATE_ _jlX � l�l i L.-
SITE ADDRESS � �f C
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
NAME:�
ADDRESS:
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #
ADDRESS:
PHONE
❑ SINGLE FAMILY
YOUR E-MAIL
❑CONTRACTOR
.. _ �J . _ �
TYPE OF WORK: I� NEW �EPLACEMENT
DETAILED DESCRIPTION OF WORK
Permit No.:_c
Received By:
Dat�d�
RCI. U
1 \( I�S`� ���
EXP DATE
CITY
FAX
FAMILY ❑ TOWNHOUSE
❑ ALTERATION/REMODEL
_i� _
STA
ATE ZIP
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: SIZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO A[R 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 $10.00 _GAS PIPING $10.00 �VENTtLATOR $15.00
0
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 c which equires review and approval of plans.
SIGNATURE OF APPLICAN����/�_ PWNT NAME�O ✓Vl_ i`� f�� ��I I S` C� DATE ��
APPROVAL INSPECTORS SIGNATURE __ _ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
lJ