P - 48301Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �Z. � ( ?
STI'E ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFEC'I'IVE 1-1-2012
YOUR E-MAIL ADDRESS
�..�., �-.1 i.
�OWNER ❑CONTRACTOR
PHONE: � 6 7j —Z.�Z ' l $ � �
�
Permit No.:
Received By:
]�ta� Rec'd: �� ���
��2
CONTRACTOR �pp,IpANY N,�:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ,e,DDRESS: CITY STATE ZIP
APPLICATION pHONE FAX
PERMIT TYPE O SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW � REPLACEMENT ❑ AL7'ERATION/REMODEL
DETAILED DESCRIPTION OF WORIC�
�
FEES ARE BASED ON S10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Fquipment Installed MFG: MODEL: SIZFJBN
MFG: MODEL:
SIZF/BTU
MFG: MODEL: . SIZEBN
A/C 525.00 _FIREPLACE (GAS) $15.00 �GAS RANGE/OVEN S10.00
_AIR TO AIR EXCHANGEER S15 _fIREPLACE (WOOD) $35.00 NEW GAS GRII.L 510.00
BOILER $35.00 _FURNACE S35.00 =GAS UNIT HTR S 10.00
CHIMTiEY LINER S10.00 _GAS DRYER 510.00 _POOL HEATER 535.00
'�ZpUCT WORK S1O.W _GAS PIPING 510.00 _VENTILATOR 515.00 __
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 es of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an ap ''on f permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case f all w r eview and appmval of plans.
.—.--,
SIGNATURE OF APPLICANT PRiNT NAME .� c�.nJ (i�sl9� �' ��DATE a I R I
APPROVAL
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977