P - 48601Building
Inspections
763-572-3604
763-502-4977 FAX
�,
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
.� � `
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT[VE 1-1-2012
�---� YOIJR E-MAIL ADDRESS 'I� h_ 1/�
1..l.�a.� ���.us�i A! Si t�a
�OWNER
ADDRESS:��(,�l�J'�
PHONE: � �j �. ' ,J � Q ^'
CITY
CONTRACTOR COMPANY NAME: N� /�'
SUBMIT A COPY OF CONTACT PERSON����
YOUR STATE STATE LICENSE # EXP DATE
LiCENSE WIT'H ADDRESS: CITY
APPLICATION
PHONE FAX
PERMIT TYPE �"'�NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK:
DETAILED DESC
❑ NEW ❑ REPLACEMENT
ON OF WORK �: t l-r �,r r,,� i
�ALTERATION/REMODEL
�
Permit No.: ���� � ��( r;�'
Received By: � �
�� � �
���
n
TA
STATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURF., EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBF,R OF E�A-C�BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUA J 20 6 ASHRAE HANDBOOK. ,�,
Equipment Installed MFG: �Z_��� MODEL: t� ��l � U� �� SIZEf��Ei- � Z��
' MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $]0.00
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 $10.00 _GAS PIPING $]0.00 �VENTILATOR $15.00
Number of fixtures @ $10.00 x $10.00 = $ �'C'� ---'
Number of fixtures @$15.00 � x$ l 5.00 =$ ���, t� c'�
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures �a, $35.00 x $35.00 = $
�'�%�
State Surcharge = $ 5.00 �� �,►
MINIMUM FEE $40.00 Total = $ ,.
THIS lS �N APPL(CATION FOR A PERMIT-NOT VAL[D UNTIL PROCESS�ll
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 th 'ty of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application o e t and ork is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work whic ' uires ' w and approval of plans.
SIGNATURE OF APPLICANT � �� RI T NAME ��✓j � ATE � ���/ � ,/ �
PPROVAL INSPECTORSS ' AT DATE
PLEASE NOTE: SEPA TE , RE REQUIRE FOR BUILDING, ELECT AL D MECHANICAL WORK
City of Fridley
y ildiog Inspections Department
3 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977