P - 35052Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �1 �1
SITE ADDRESS ��
THIS APP[.ICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPR
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
❑ OWNER
ADDRESS:
COMPANY NAME: '
CONTACT PERSON:
YOUR E-MAIL ADDRESS ��
`✓� �,r' �`�
)NTRACTOR
� � CITY
� — � Lj
Permit No:
Received By;
� �y� '� � � _ � 1
STA
STATE LICENSE # EXP ATE rt
ADDRESS: CITY STA��IP iJ.lU
PHONE �" ' FAX �IA� � _
TYPE OF WORK: I� NEW
LE FAMILY ❑ TWO FAMILY
DETAILED DESCRIPTION OF WORK
REPLACEMENT
❑ TONR�IHO1ISE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (iNDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUA J 2006 ASHRAE ANDBOOK. r��\�� ��� L
Equipment Installed MFG: MODEL��°�'-�1���=��� "'_ Ir�IZE TU
A/C $25.00
_AIR TO AIR EXCHANGEER $15
_BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
�FURNACE $35.00
GAS DRYER $]0.00
GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS LJNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 ordina an s of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an ap licat n or.a ermit and work is not to start without a perm • that the work will be in accor ance ith the
approved plan in the case a�w r hic q�jires review and approval of pjaqs. „�/� �/ �� ��,,,„ ��. /� �
SIGNATURE OF APPLICANT
APPROVAL
DA
�/ City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977