P - 37147Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-1-2010
DATE I �' � � �'
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
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� OWNER
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ADDRESS:�
PHONE:ZC��-7' �
_ YOUR E-MAIL ADDRESS
❑CONTRACTOR
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Permit No.:
Received By:
te Rec'd:
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CITY � � � � `""�-' � STAT�
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PER50N:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: CITY
APPLICATION
PHONE FAX
PERMIT TYPE SINGLE FAM]LY O TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMEiVT ,�ALTEitATION/REMODEL
DETAILED DESCRIPTION(OF
�,
�'�f`�1`ii t�1�i-c- 4 1 !l� S
ATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE IVOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: S[ZEBTU
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
~AIR TO AIR EXCHANGEER $] 5 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
X_DUCT WORK $10.00 GAS PIPING $10.00 ?�VENTILATOR $15.00
� TH[S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply a buiiding 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 app cation for a permit and work is not to start without a permit; that the work wiil be in accordance with the
approved plan in the case o�ll work w ic�t quires review and approval of plans.
SIGNATURE OF APPLICAN � '� i't/"� PRINT NAME �J ��' ��" f`--���,'��? f�>� DATE I I' O�`/��
APPROVAL INSPECTO SFU�N � , °" � ��---'° DATE ��� �� " ��
City of Fridley
ilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977