PERMIT - 35049Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE �-i-ZOI�
vn� �-I' [ v_ C� ( �
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
❑ OWNER
li:[� �7�I�I%r�
E-MAIL ADDRESS
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Permit
Rec�}v�d R��rl�� ��, .
Dat�d� � J � � ���� .
STA'I'�%�/ (LIP
CONTRACTOR COMPANY NAME: S � L `� X.. ' / l
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SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EX/P �DATE �-y�,�
LICENSE WITH ADDRESS: // CITY STA'I'�/.� �IP
APPLICATION pHONE 1 �" " FAX � ��'
PERMiT TYPE
TYPE OF WORK:
DE�.
O�INGLE FAMILY ❑ TWO FAMILY
.�
❑ NEW �REPLACEMENT
OF WORK
❑ TOWNIiOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTIJRES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANiJ 2 E HANDBOOK. / ��/,,� /„J� n yt x
Equipment Installed MFG: MODEL: �1��+�%V�.P"/(..[l/�/ SIZE/BTU 1�����i(.
MFG:
MODEL:
SIZEBTU
MFG: MODEL: SIZEBTU
_A/C $25.00 FIREPLACE (GAS) $I5.00 _GAS RANGF/OVEN 510.00
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 $10.(� VEN'TILATOR $I5.00
Number of fixtures @ $10.00 x $10.00 = $ ' ,
Number of fixtures @ $15.00 x $15.00 = $
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @�35.�0 L x$35'.00 =��' W
State Surcharge = $ 5.00
(MIlYIl41TT1�I FEE $40.00) Tota1= $ �V • �
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 of all rk wh' i requ' es review and approvai of plans.
SIGNATURE OF APPLICANT PRINT NAMEi��/ /I / 1 +��rL(�N��L ��E1T� ° �/ , `-'�l
._ �
APPROVAL INSPECTORS SIGNATURE
DA
�`" City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977