P - 45835Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �`�1J
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-20] ]
YOUR E-MAIL ADDRESS •
O OWNER ❑CONTRACTOR
NAME:SJ(
ADDRESS:
PHONE:�
COMPANY NAME:_
CONTACT PERSON:
STATE LICENSE #_
ADARESS:
PHONE
�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK �/1� "]F0.�/�
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EXPDATE
GTY
FAX
❑ TOWNHOUSE
�ALTERATION/REMODEL
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::�:�r� -- �"�? c `��"
Permit No.:
Received By:
Date Rec'd: � � �
_STATE �'I�IP�
STATE ZIP
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
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 FURNACE $35.00 GAS UNIT HTR $10.00
_CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK $]0.00 _GAS PIPING $10.00 ��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 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 w�ich requi�revi�approval of plans.
SIGNATURE OF APPLICANT � PRINT NAME ��i't� LQ, a�Y��y' DATE �,�� �� f
AL INSPECTORS SIGNATURE
DA
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977