P - 39654Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX Ex�cTTVE a-i9-o�
SITE ADDRESS i_
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
F' � �i�l�fl.���l
TYPE OF WORK:
YOUR E-MAIL ADDRESS
❑ OWNER L7CON'I'RACTOR
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COMPANY Nt1ME: �
CONTACTPERSON:
STATE LICENSE # L
CITY
EXP DATE . '"5 '
CITY ' ? l %l�i/�
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1�l SINGLE FAMILY ❑ TWO FAMI1,Y
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❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNIIOUSE
'L� ALTERATIONJREMODEL
/ll ' �
Permit No.:
Received By;
Date Rec'
�
A'I��ZIP
ATF%�_/�IPJ-'/��
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBII2 OF EACH BELOVI�
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZEBTU
A/C $25,00 _FIREPLACE {GAS) $15,00 GAS RANGEIOVEN $10.00
AIR TO AIR EXCIiANGEER $IS �FIREPLACE (WOOD) $35.00 `NEW GAS GRILL �10.00
BOIL,ER $35.00 FURNACE $35.00 GAS UDIIT HTR $20.00
CHIMNEY LINER $10.00 GAS DRYEK $10.00 `POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 ^VENTILATOR $I5.00
THIS IS AN APPLICATiON FOR A PERMIT-NOT VALID iJNTIL FROCESSED
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 �onstruction 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 work w� h require review and approval of plans.
SIGNATURE OF APPLIC Q PRINT NAME �, 4 � ATE ,� a'� �
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-5�2-3604 FAX: 763-502-4977