P - 36725Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-1-2010
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SITE ADDRESS ! �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
YO R E-MAIL ADDRESS
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❑ OWNER �CONTRACTOR
NAME:
ADDRESS: i� Uv �7J��fl��� • �v�
PHONE:
COMPANY NAME: or µiC,a .
CONTACT PERSON: 3a1 S�n �,�.�
STATE LICENSE #
ADDRESS: � ��
PN(1NF1 Ii IY� 5��� S� FAX
TYPE OF WORK: + � NEW
FAMILY ❑ TWO FAMILY
O REPLACEMENT
DETAILED DESCRIPTION OF WORK
A �� . .._ �n �-�t�' �f`.� c�.: � _'.,a r-a—h,�,r
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Permit No.
Received By:�_
TATE I��ZIP
EXP DATE
_CITY n d K�n STATE�ZIPSS3�3
❑ TOWNHOUSE
TERATION/REMODEL
f
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Instailed MFG: MODEL: SIZEBTU
MFG:
MODEL:
SIZE/BTU
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 S 10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
,�cDUCT WORK$10.00 _GAS PIPING $10.00 _VENTILATOR$)5.00
THIS IS AN APPLICAT[ON 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 permit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all yyork whic�h requires review a►�d appro�al of plans.
SIGNA'CURE OF APPLICANT
APPROV
DATE ! ��-! /��
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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