P - 35090Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX FFFF�T,,,F,_,_��„
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
�U ��
❑ OWNER
ADDRESS:
E-MAIL AI3DRESS
CONTRACTOR COMPANY NAME: QC.A�(11 � ' C
SUBMIT A COPY OF CONTACT PERSON: /i
YOUR STATE STATE LICENSE # SS EXP DATE �J
LICENSE WITH ADD�ss:�2�41 R�-n,�in CITY �
APPLICATION pHONE ��� JJ�g Co%DCa FAX ��� ��v� c,`,
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT L�SALTERATION/REMODEL
DET
%/1T
OF WORK
�3°IT
Permit No.:
Received By, f
D����' d�: U
TE ZIP.
5 STATFJ'"/�IP�
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! /I S�LT $ �/�✓?77I'/
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE AEAT LOSS CALC'S PER MANUAL d 2(N16 ARNRAE HANDBOOK p0�
Equipment Installed MFG: _�iN.tJ i2. MODEL: �� Z� SIZEBTU ��P i
MFG:
MODEL:
SIZE/BTU
MFG: MODEL: SIZEBTU
_A/C $25.00 FIREPLACE (GAS) $15.00 — f /I SG�-T _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 i1NTT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 _POOL HEATER $35.00
�DUCT WORK $10.00 �GAS PIPING $10.00 VENTILATOR $I5.00 '
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 ermit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of ali work which e'res review and approval of pla
SIGNATURE OF APPLICANT PRINT NAME �`�Q ��'�� / I J'�� �!
DATE
............. ._.�,,,...T,.,.� �...�..�...,.., ��IADri► ,..T., "� � ,
U City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977