P - 59368Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE i-i-ZOia
DATE��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
❑ OWNER
ADDRESS:
PHONE: '
E-MAIL ADDRESS
Permit No
Received By: � �
����c� � �� a. �
TATE ZIP
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE #����(��/ ��rr� EXP an o a r
L�cENSEw�TH ADDRESS: �P.�,{�. Idl� � Shako�aee MN 55379 STATE ZIP
APPLICATION pHONE � ` FAX 9,�ii�,d��RA'�
PERMIT TYPE
TYPE OF WORK:
SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �'�ACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
0
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 HANDBOOI{.
Equipment Installed MFG: MODEL: SIZEBTU
_A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
_FIREPLACE (WOOD) $35.00
FURNACE $35.00
�GAS DRYER $10.00
GAS PIPING $10.00
SIZEBTU
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
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 codes of City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application a pe it a d work is not to start without a permit; that the work will be in accordance with the
approved plan in the case ofiall work wh equire� review and approval of pla�s. I �� •_,'
,)�/ I I ��.
SIGNATURE OF
APPROVAL INSPECTORS SIGNA
DATE
/ City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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