P - 46709Building
Inspections
763-572-3604
763-502-4977 FAX
V DATE�U-�I -
/�� SITE ADDRESS ,��
° \ / THIS APPLICAN"f IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
DETAILEDt DESCRI
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
ADDRESS
❑ OWNER
COMPANY NAME:�
CONfACT PERSON:
STATE LICEtNS—E� #�_
ADDRESS � 1D�/�1
��;c.�.t��-.z�
/�INGLE FAMILY � TWO FAMILY
�
❑ NEW �EPLACEMENT
1
OF
�
Permit No.:
Received By:
�....
� '�
EXP 1�/(TE _ ' �
\b �3 y ci� _ ,_i
.� -�k���l �-�
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
� - _ _.
�
FEES ARE BASED ON $lO.Od.�ER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�
PROVIDE HEAT LOSS CALC'S PER MANU �_L �J,,�20�0 A�,S,�HRAE HANDBOOK nA
Equipment Installed MFG: ��=��Y'\ MODEL: ��W— SiZE/BTU
MFG: MODEL: SIZEBTU
MFG: MODEL: StZE/BTU
A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGF/OVEN SI0.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 �'URNACE $35.00 GAS UNIT HTR $10.00
Ci�4NEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTII,ATOR $15.00
Nvmber of fixtures @ $1Q.00 ' x $10.00 = $ '
Numbar of fixtures @ $15.00 x $15.00 = $
Number of fixtures @ $25.00 x $25.00 = $
�
N�tnber of fixtures @ $35.00 � x $35.00 = $ �
State Sureharge = $� 5.00
< c�v
(1Vfl(NiMi7M FEE S40.fIQ) Total ° $ ��'�f .
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
confortnance 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 ermit d ork is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work w'c ' e 'ew and approval of plans.
SIGNATURE OF APPLICANT
r,�(! � PRINT NAME `� '�_ ��� DATE I � I I
SIGNA
City of Fridley
ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 �FAX: 763-502-4977
/ �" G /