P - 35059Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-572-3604 CITY OF FRIDLEY
763-502-4977 FAX _ EFFECT�vE �-�-ZO>> ,.,
DATE � / o[ - �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY N
OWNER/ A
TENANT
❑ OWNER
YOUR E-MAIL
CITY
Permit No.:
Received By:
Date��i:�
A
CONTRACTOR COMPANY NAME: �-t � r
SUBMIT A COPY OF CONTACT PERSON: r-.r t.�� /l/� G��� �� �
YOUR STATE � STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: L` c CITY y�L�% � STATE�ZIP
APPLICATION
PHONE D FAX
PERMIT TYPE
TYPE OF WORK:
FAMILY ❑ TWO FAMILY
❑ NEW O REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
TERATION/REMODEL
�
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE 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 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 �P'�OO:L HEATER $35.00
_DUCT WORK $] 0.00 _GAS PiPING $10.00 Xv tNTI LATOR $ I 5.00
TH1S IS AN APPLICATION FOR NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowled he infor ation above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the ' .cidley a with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicatio rm a d is not start without a permit; that t6e work will be in accordance with the
approved plan in the case of � �r�ir view an approval of plans. , f ,
SIGNATURE OF
APPROVAL
TURE
PRINT NA
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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