P - 35463Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRE S �"'
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
DETAILED
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
❑ OWNER
NAME:�,,,
ADDRESS:
COMPANY NAME:_
CONTACT PERSON:
YOUR E-MAIL ADDRESS _
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ONTRACTOR
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Permit No.:
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TE /h!'ILIP
STATE LICENSE # EXP DATE
ADDRESS: �� /�I C� C� ��- So�''l / U w'"� r�-�+ C1TY 1 LY �� STATE ��L[P
PHONE �'i�..�" - Ll ��- l�' (,) _ ?j'% � j` FAX �I � �"" —L f"y'U — ("_I 1-J' li
L�NGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
OF WORK
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❑ TOWNHOUSE
�i1LTERATION/REMODEL
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FEES ARE BASED ON $10.0(1 PER FIXTURE, EXCEPT WI�ERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
MFG: MODEL: ` SIZEBTU
_A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 _FURNACE $35.00 _GAS UNTI' HTR $10.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
1r1 DUCT WORK $10.00 GAS PIPING $10.00 _VENTILATOR $15.00
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 ork is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all w which require ;eview and approval of plans.
SIGNATURE OF APPLICANT r L" tr�� �-"�,_i'�`�'+"PRINT NAME �LL�� �`�'� S L GZ (/ WL(DATE �D , i I D
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APPROVAL INSPECTORS SIGNANRE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977