P - 45504�uilding
. Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201 I
❑ OWNER
NAME: �J
ADDRESS:
PHONE:�
COMPANY NAME:
D� E- AIL ADDRESS
�
ITRACTOR
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Permit No.:
Received By:_ �d�
Date .� ��1- �r .�
ATE Z[P
SUBMIT A COPY OF
CONTACT PERSON: �'namPlOCI PIURlblflg
YOUR STATE STATE LICENSE # P DATE
LICENSE WITH ADDRESS: 36'78 L�A�a p�Q-CITY STATE ZIP
APPLICATION pHONE Eagan, Mi"►�°�$5y��
FERMIT TYPE
TYPE OF WORK:
[�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ 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 MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZEJBTU
A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
_CHIMNEY LINER $10.00
DUCT WORK $]0.00
MFG:
MODEL:
MFG: MODEL
FIREPLACE (GAS) $ I5.00
FIREPLACE (WOOD) $35.00
�F RNACE $35.00
S DRYER $10.00
GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
_POOL HEATER $35.00
V ENTI LATOR $15.00
THIS IS AN APPLICATION FOR A PERM[T-NOT VAL[D 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 work which requires review and approval of plans.
p y �` ,.�/� ,�,/ , T
SIGNATURE OF APPLICANT J PRINT NAM ��(„� (J ,/!� (,,r DATE
APPROVALINSPECTORS NATURE 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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