P - 48229Building MECHANICAL Permit No.: f(}� (��
Inspections RESIDENTIAL APPLICATION Received By: `��� V
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011 � ��� — ' '
DATE� ` YOUR E�MAIL ADDRESS
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
❑ OWNER
COMPANY NAME:
CONTACT PERSON:
STATE LICBP'SE # I
PHONE
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i�� Y '_?XP DATE
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1''� C I�� FAX � ,� , -
PERMIT TYPE � SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � �W '�PLACEMENT
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'�"OWNHOUSE
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❑ ALTERATION/REMODEL � ��
FEES ARE BASED ON 510.00 PER F'IXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�
PROVIDE HEAT LOSS CALC'S PER MAN�L 0`�� E HANDBOOK "� �L�i— —�
Equipment Installed MFG: MODEL: U��3 SiZE/BN
MFG: `�1 MODEI,: � ? �� � SIZEBTU _ ����
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGFJOVEN $10.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD}$35.00 NEW GAS GRILL $10.00
_BOILER $35.00 �FURNACE $35.00 _GAS UNIT H1R $10.00
_CHIIVINEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $t0.00 GAS PIPING $10.00 VENTiLATOR $15.00
Number of fixtures @ $1Q.00 x $10.00 = $
NUmber of fixtures @ $15.00- x $I5:00 = $
Number of fixtures @ $25.00 x $25.04 = $
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Number of fixtures @$35.00 � x$35:00 =$3�
State Succharge ° $ 5.00
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(MINIlVIi3M FEE 540.00) Total = $ ��, — -
�� 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 an 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 whic uire review and approval of plans.
S[GNANRE OF APPLICANT �. A � PRINT NAME `—'V °�' � `��i TE%i- � 1-T+�
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City of Fridley
B ' ding Inspections Department
niversity Avenue NE, Fridley, NIN 55432
763-572-3604 FAX: '763-502-4977