P - 60369� Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE
STTE ADDRESS
THIS APPLICANT IS: OWNER
PROPERTY NAME: �
OWNER/ ,�pD�ss: `�I
TENANT , ,�
YOUR E-MAIL ADDRESS
BL{ONTRACTOR
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Permit No.:
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Received By:
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ATFI��^'LIP
CONTRACTOR COMPANY NAME:� _�M1_�'i � -�C � �tQ�'�-� —
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SUBMIT A COPY OF CONTACT PERSON: /Y! D ISD � _ —
YOUR STATE STATE LICENSE # EXP DATE
LICENSEWITH �D�tESS: ��ac.rS'1�n � �w ���' ci'rY_ ri[/le�e-a- STAT'EM�ZIP�sf�j
APPLICATION � 3 s yr�, ���/ --- F� Z? ��� ��� �
PHONE _ �7
PERNIIT TYPE
TYPE OF WORK:
Ci�SINGLE FAMILY ❑ TWO FAMILY
� REPLACEMENT
DETAILED DESCRIPTION OF WORK
O TOWNHOUSE
❑ ALTERATION/REMODEL
or1� i a� ����'CS °� �^
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: _ MODEL: SIZFJBTU
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 UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
\/�UCT WORK $10.00 GAS PIPING $10.00 �1/' 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 pernvt but only an applic ion a permit and work is not to start without a permit; that the work will be in accordance with the
approved pian in the case o all ork wh� re review and approval of pl s.
i j�
SIGNATURE OF APPLIC PRINT NAME � rn v��� DATE I��' _�
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APPROVAL INSPECT SIGNAT // / _ DATE � /�
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977