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Building MECHANICAL
�rispec�ions RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
'���'=502-4977 FAX EFPECTIVE 1-1-2011
DATE
SITE ADDRE S � r�
THIS APPLICANT IS: ❑ OWNER
PROPERTY NAME:
OWNER/ ADDRESS:
TENANT
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
COMPANY NAME: �
CONTACT PERSON:
STATE LICENSE # �
PHONE
YOUR E-MAIL ADDRESS
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�E NTRACTOR
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CITY
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�g, � EXP DATE
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"Li' � � � FAX `�1�- G �-f I "�
�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW r �REPLACEMENT
� �
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
Pernut No.:
Received By:�
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ATE ZIP
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FEES ARE BASED ON $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. 31�AQ��U��-lo SIZEBTU ��yp�—"S�
EquipmentInstalled MFG: VLnGVt-i� MODEL:
/
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C 525.00 _FIREPLACE (GAS) 515.00 _GAS RANGE/OVEN 510.00
AIR TO AIR EXCHANGEER S15 FIREPLACE (WOOD) $35.00 _NEW GAS GRILL 510.00
_BOILER S35.00 �FURNACE 535.00 _GAS iJNIT HTR 510.00
_CHIMNEY LINER 510.00 _GAS DRYER 510.00 _POOL HEATER a35.00
_DUCT WORK 510.00 ___GAS PIPING 510.00 _VENTILATOR 515.00
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Number of f�tures �,a7 $35.00 x $35:� � '�
�tate Suxcharge = $ 5.�1
[� �p
(MINYMUM FEE �4b.001 Total = � f �� �
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 appl'cation for a permit and work is not to start without a pecmit; that the work will be in accordance with the
approved plan in the cas�.e��1J�wQrk whic,h�req�}fr�s xqview and approval of pl�a�s. , , ,
SIGNATURE OF APPLICA
APPROVAL INSPECTORS SI(
PLEASE NOTE: SEP
PRINT NAME
� City of Fridley
Buii ng Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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