P - 35263Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE i-i-zoi i _
DATE ' -
i
SITE ADDRESS C
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
r
` YOUR E-MAIL ADDRESS
❑ OWNER
NAME: l T�-r r t�l- �O !�7 L QYYC
ADDRESS: �Q.� }'j,Q� CITY
PHONE:
Permit No.:
Received By: I �%'
Date�c�l: � �
ZIP
CONTRACTOR COMPANX N �
SUBMIT A COPY OF CONTACT PE
YOUR STATE STATE LICENSE # O 3 O ii ��O E� D�t� l3g7 STATfON PARKWAY N.� �<
LICENSE WITH �DRESS: '• r�CiTY ���ii. MPt 55304 �TATE ZIP
APPLICATION pHONE FAX ��`���
PERMIT TYPE
TYPE OF WORK:
�6rINGLE FAMILY
❑ �w
DETAILED DESCRIPTION OF WORK
❑ TWO FAMILY ❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASEDAN $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 Installed MFG: MODEL: SIZEBTU
MFG: ��'eyK' MODELf��TI'1�D�d SIZEBTU ��'Z-
MFG: MODEL: SIZEBTU
I 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 iJNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
Nurnber of iixtures � � 10:OU ' x $10.40 = $ � R � �
". . ,��
Number of fixtures @$15.00 x$15 A� _$ -
Number of fixtures @ $25.00 � x $25.00 = $_��_�
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ 5.00
(MINIMUM FEE $40.00) Tota1= $ y� � �
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 ap ' tio f r 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 which u' rev' a,�d approval of pl . T
SIGNATURE OF APPLICA L%� PRINT NAM�G%' //nll�GL `� CJ�-� �aC�E", �!/��
APPROVAL INSPECTORS SIGNATZTRE �O�' +��(/�j�F��/ DA
City of Fridley
ilding Inspections Department
6431 UniversiTy Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977