P - 50460Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.:
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Date ec d:
DATE `�`� —�— I Z YOUR E-MAIL ADDRESS �-� � C'J fK C� G��. C� V'C►�< �- C�'`"
SITE ADDRESS �� `1 � k�'rh` k= � I�-1 )C=
THIS APPLICANT IS: ❑ OWNER L�NTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
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ADDRESS: C1TT'.
PHONE:
COMPANY
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SUBMIT A COPY OF CONTACT PERSON: �A Lj �� �
YOUR STATE STATE LICENSE # EXP DATE /
LICENSE WITH pDDRESS:� D� �n CITY 1��,`ti ��c ��� STATP�.� ZIP,��
APPLICATION pHONE 1�,\� -����Y=t % JI FAX
PERMIT TYPE
TYPE OF WORK:
❑ SINGLE FANIILY ❑ TWO FAMILY
❑ NEW �$EPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASARAE HANDBOOK
Equipment Installed MFG: MODEL: SIZE/BTU
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $I5.00
AIR TO AIR EXCHANGEER $15 _PIREPLACE (W�D) $35.00
BOILER $35.00 _FURNACE $35.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00
DUCT WORK 510.00 GAS PIPING 510.00
SIZE/BTU
SIZE/BTU
_GAS RANGE/OVEN $]0.00
NEW GAS GRILL $10.00
_GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTiLATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 C' o idley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit an r is not to start without a permit; that the work will be in accordance with the
approved plan in the ca� o��aTl°'vv�rk which requ' view and�prov�]_of plans.
SIGNATURE OF
APPROV,
,---
NAME s\'�5�� � ' -ti E,JL � DATE �'— % ' I �7
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977