P - 50468Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-SOZ-49�%% FAX EFFECTIVE 1-1-2012
DATE 2 d ��' YOUR E-MAIL ADDRESS I✓� ��=^ l� V
SITE ADDRESS '
THIS APPLICANT 1S
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
Permit No�j�?-005 �
Received By: `
Date Rec'd: y 2
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�WNER ❑CONTRACTOR
NAME: �' �i � \O �i �1
ADDRESS: �� � S �1, v�t-- C1TY STATE ZIP.
COMPANY NAME:_
CONTACTPERSON:
STATE LICENSE #_
ADDRESS:
PHONE__
FAIvIILY
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❑ TWO FAMILY
TYPE OF WORK: I� N� ��PLACEMENT
DETAILED DESCRIPTION OF WORK
FAX
EXP DATE
CITY STATE ZIP
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZFIBN
MFG: MODEL: SIZFJBN
MFG: MODEL: SIZE/BTU
A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $I0.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 _NEW GAS GRiLL �10.00
$OILER 535.00 FURNACE 535.00 _GAS iJNTT HTR 510.00
_CHININEY LINER $10.00 �C'r'�i5 DRYER $] 0.00 POOL HEATER $35.00
DUCT WORK 510.00 _GAS PIPING $10.00 VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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; that the work will be in accordance with the
approved plan in the case of all w '�eq.t�res review and approval of plans.
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SIGNANRE OF APPLICANT PRINT NAME DATE
APPROVAL INSPECTORS SIGNATURE -�1�;L�'-( _ DATE 7'�� /�
� City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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