P - 39771,
Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECT�vE �-i-aoi�
DATE «' � �, ( 1 1
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
NAME:
PHONE:`
YOUR E-MAIL ADDRESS
(`.if �::.��. ��?J (�,3 �
❑ OWNER I�ONTRACTOR
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3: 1�� �-}- �-i�! ���' Y'fi��. �•�__Nr--� c�TY
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COMPANY NAME: ��C
CONTACT PERSON�
STATE LICENSE #�
ADDRESS:�'"�, d �
PHONE�L1?�'j' `�-7 Z-
Permit No.:
Reeeived By:
Da�' d,;�
J � `j'�i"t.%�,� 4�'�I�VY11'�i%'1C��
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; % EXP DATE L� � 2(� �
���� W�L-rt:� 1�-�� CITY�__ �I I ti� 4'1��� �'� i
�,�-1 FAxql�-�' 4��5i��)a`I �
L�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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STATE���1P �;
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ATEC 11� ZIP ��_/
FEES ARE BASED 01�I $10.00 PER FIXTURE, EXCEPT WHERE NOTEB. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU�J 2006 ASHI�AE HANDBOOK,
Equipment Installed MFG: ��� MODEL: SIZE/BTU
MFG:
MODEL:
SIZE/BTU
MFG: MODEL: SIZE/BTU
�A/C $25.00 ' l � _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 $10.00 GAS PIPING $10.00 VENTILATOR $] 5.00
Number of fixtures @$10.00 I x$10.U0 =$.
Number of fiactures @ $15.00 x $15.00 — $
Number of fixtures �,?a $25A�J x $25.00 = $
Number of fixtures @ $35.00 x $35.00 , $
State Surcharge = $ S.QO
(MINIMUM FEE $40.00) Total = $ �% "V �
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 Ciry of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application ermit an work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all k wh' eyuir review and approval o�plans.
SIGNATURE OF APPLICANT/ Y1 1 e J � PRTNT NAME� �G�����, (! � I�LLi✓� DATE �j l.� J��/% �/
APPROVAL INSPECTORS SIGNATURE
PLEASE NOTE: SEPARATE ]
�'� DATE �
E S RE UIRED FOR B LDING, ELECTRICAL .
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: ?63-502-4977
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