P - 35061Building
Inspections
763-572-3604
763-502-4977 FAX
DATE l � � l U
SITE ADDRESS �"��
THIS APPLICANT IS:
PROPERTY NA
OWNER/
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL
OCONTRACTOR
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TENANT ADDRESS: i`f'"1 -f b'�1 �� J`r' i
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #_
ADDRESS:
PHONE
❑ SINGLE FAMILY
TYPE OF WORK: I� NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
y
EXP DATE
C[TY
FAX
FAMILY ❑ TOWNHOUSE
� ALTERATION/REMODEL
Permit No.;��ry "`'
Re '� � B �
,
Date ec'�
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STA7'E, �IP
STATE ZIP,
EEES 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: SIZEBN
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $15.00 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 $]0.00 POOL 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 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 o work requires review and approval of plans.
�`' ..�� �.- � �.
SIGNATURE OF APPLICA PRINT NAME` G�/Y�,1 1 V �SI C.�llATE �
APPROVALINSPECTORSSIGNATURE 1�ATF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley,lVlN 55432
763-572-3604 FAX: 763-502-4977