P - 48331Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY �F FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE � ��I .`_7�-�
sr� a.DDxESS F
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
Permit No.:
Received By:�l�` ��_
Date �i�: � , .;
e,. 1""? ` � �'�
C� .
YOUR E-MAIL ADDRESS .5�-�_-, . ' c �...
�l r ", i f � � , i- ''�L i ) i �, vr.�, .+! `�S� Y '2
�OWNER ❑CONTRACTOR
_�
NAME: � ��i.�P s �'�rtiti�a,;.l e - —
ADDRESS: , l,, fo 5 1�-'v � � � � -� / C , .ti--�_CITY ► ✓; L�. � STATE i2�,-iZIP� t
PHONE:��. I Z -�i � " — "7�`J �, c.
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE # EXP DATE
ADDRESS: CITY STATE ZIP
PHONE FAX
�Sl SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
❑ NEW �1 REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK
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: SIZEBTU
MFG: /� r�W � 1 MODEL: SIZEBTU
A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
�FURNACE $35.00
GAS DRYER $10.00
GAS PTPING $10-00
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS LTNIT HTR $10.00
POOL HEATER $35.00
VGNTTLATOR $15.00
Number of fixtures rr $3�.00 _____ x$3�.QI} —$
Staie Surcharge — ' r ,� � � $ 5.00'
�
(MFl�lllqCJN1 FEE $40.Q4) 'TQtal -- $ ' :°``s .� �
��/. TH1S 1S AN APPLICATION COR A PLRMIT-NO"C VALID UNTIL PKOCESSED
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 al� rk whi eyuires review and approval of plans.
SIGNATUREOFAPPLICANT � y( - PRINTNAME .�Glv��>� G� >{�,c'.�^ DATE 1 �.3(.��I Z
APPROVAL INSPECTORS SIGNATURE __ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977