P - 45771Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CIT� OF FRIDLEY
763-502-4977 FAX
EFFECTIVE 1-1-2011
DATE l�i � � •
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
❑ OWNER ^
YOUR E-MAIL
ci�
Permit No.:
Received
Da�d'
ATE ZIP
PHONE:
CONTRACTOR COMPANY NAME: S �
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXi' DATE �,,
LICENSE WITH ADDRESS: ���� "�'�_� ��(�� I,� ��� � �`�[, CTTY � {� �(f�1� STATE�� 2IP.
APPLICATION pHONE �� _� �� � ' ���_ FAX
PERMIT TYPE I'-"/�:')GLE FAMILY � TWO FAMILY
TYPE OF WORK: I a�W
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
� ALTERATIONIREMODEL
FEES ARE BASED ON $10.00 PER FTXTURE, EXCEPT WHERE NQTED. FIXTURES: (INDICATE TOTAL N[IMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUAL� ,20�06�� A�SHRAE IIANDBOOK /� �" �"' j�
Equipment Instailed MFG: --��-y=— MODEL: ��% V� SIZE/�TU �J� �. l�
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZE/BTU
_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 �'URNACE $35.00 GAS [7NTf HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WOItK $10.00 _GAS PIPING $10.00 VENTILATOR $15.00
Ntlii1tT61',OI #17EtUTC3 (� �33.UU X ���:U4? = �
�tc1�E �JIFiC�'iRi�C s $ �.�Q
�MINIMQM FE;E �dO.Ob} `�'Ota1=' � ° ! � Y��
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID IJNTIL 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 pei,� it and work is not to start without a permit; that the wark will be in accordance with the
approved plan in the case of ° which /�quires review and approval of plans.
SIGNATURE OF APPLICAhIT �� :����� PRINT NAME ( A�, X i r 1�1 /�E �/! � I�� I 1 1
APPROVAL
DATE
City of Fridley
Bu lding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
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