P - 62702Building
Inspections
763-572-3604
763-502-4977 FAX
DATE -1 1 "� � ,
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
m
MECHANICAL
' RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFF,CTIVE 1-1-2012
2 E-MAIL ADDRESS
❑ OWNER
NAME:� _ 6�1�) Y I'�
ADDRESS: � ��,G� CITY
PHON E: � ��_—��—�!���.id-�
COMPANYNAME:
CONTACTPERSON:
STATE L[CENS6 #�'�
ADDRESS:
PHONE
�INGLE FAMILY ❑ TWO FAMILY
❑ NEW �REPLACEMENT
DETAILED DESCRIPT[ON OF WORK
EXP D��'13 Dan
i�'��--�'
FAX Ae� wAC
❑ 'I'OWNHOUSE
❑ ALTERAT[ON/REMODEL
Permit No.:
Received By
Date Rec'd:
DGf''ll A � � '� � �
TATE
STATE_ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEP7' WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 200G ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG:
M011EL:
SIZE/BTU
MFG: MODEL: SiZE/BTU
A/C $25.00 FiREPLACE (GAS) $I5.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 PIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UN[T HTR $10.00
_CHIMNEY LINER $10.00 �GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
Number of fixtuxes @ $10.00 x $10.00 = $
Number of fi�ctures @ $15:00 x $15.00 ° $
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ 5.00
(MINIMUM FEE $40:00) Total = $
�a °-�--
THIS IS AN APPLICATION FOR A PERMIT-NOT VAI.ID UNTIL PROCESSED
[ hereby apply for a building per►nit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of t City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe 't nd work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of a�l work �n►1Lch re u' es review and approval of p,�ans. _ � � �
SIGNATURE OF
APPROVAL INSPECTORS SIGNA'PURE
PLEASE NOTE: SEPARATE l
NA
DA
City of Fridley
uilding Inspections Department
University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977