P - 40239Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE �-�-ZO�,
DATE `� ' `�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY NAME:�
OWNER/ ADDRESS:
TENANT
YOUR E-MAIL ADDRESS
OWNER �CONTRACTOR t
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Permit No.:
Received By:
Date B��'d:
�'1�-L� � G �/ STA
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CONTRACTOR COMPANY NAME:�� � ic'�1 � �� ('7'� � J ,� � � S r �--?'m
SUBMIT A COPY OF CONTACT PERSON: c,J %?'Y� '(:} /�; p� ���� LC,�.- �J
YOUR STATE STATE LICENSE # EXP D TE
LICENSE WITH ADDRES�j�� �� j � I�j� — I�- r�'�CITY '�-� I� ;1� STAT�ZI
APPLICATION PH�,�, _._�.�� _� 7�C � FAX t
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PERMIT TYPE
TYPE OF WORK:
Q SiNGLE FAMILY ❑ TWO FAMILY
\
❑ NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
C
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTLIRES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU L J 200 AS�-1RAE HANDBOOK.
Equipmentlnstalled MFG: 1v� �(� �F�y.���MODE��o� � �b�f��S[ZE/BTU a_�
MFG:��� 'I�� MODEL C "b�C����� SI TU ,��-Q-Z.'Cdl-�
MFG: MODEL: SIZE/BTU
�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 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 $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 permit and work is not to start without a permit; tha the work will be in accordance with the
approved plan in the ca� of�aTDwork whic quires review and approval of pl s.
SIGNATURE OF APPLICANT � PRINT NAME�� � �Q
' �- ,,/� �' ��--�1
�-i�V"� � °�ATE l �
APPROVAL INSPECTORS SIGNA DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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