P - 84369Building MECHAI�TICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE � l _/
SITE ADDRESS � � e
TH1S APPL[CANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
I��i:�u'IYIIIM'/��I
TYPE OF WORK:
YOUR E-MAIL
�WNER ❑CONTRACTOR
Permit No c:/`V �d �
Received By:
,�- �-
, � �.
NAIv1E: �L � dC � �� �� �V G�i�
ADDRESS: �' Gli�--e Ove- D(!�'C CITY STATE Z1P
PHONE:
COMPANY NAME:
CONTACTPERSON:
STATE LICENSE # EXP DATE
ADDRESS: C[TY STATE ZIP
PHONE
❑ SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �"�EPLACEMENT
DETAILED DESCRIPTION OF WORK
FAX
❑ 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: SIZE/BTU
A/C $25.00
_AIR TO AIR EXCHANGEER $ I S
_BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
1�FURNACE $35.00
GAS DRYER $10.00
GAS P[PING $10.00
SIZEBTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
TH1S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
t 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.
SIGNATURE OF APPLICANT � PRINT NAME /`I �•C.-�G � 0`����BATE /`� /�� �
AL INSPECTORS SIGNATURE
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977