P - 47271Build�ing MECHANICAL
I�spections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX
, EFFECTNE 1-1-2011
DATE I , — c�—
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
OWNER �ONTRACTOR
ADDRESS: CITY
PHONE: !C� I� 7'- (� .
CONIl'ANY NAME:
CONTACT PERSON:
STATE LICENSE #
PHONE
EXP DATE
��,
FAX"! �� - G .
�INGLE FAMILY ❑ TWO FAMILY
❑ NEW i�REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
Permit No.: �,0 � -�p2�
Received By:I � �Vti'
Date Rec'd:
L71�Lr.°!� k . ,;;� , : � SJ � � � �
'ATE ZIP
ATE�ZIP SS'f I �1
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 �(�y�,r-�
Equipment Installed MFG: Y( Y� MODEL: y��j��,Vt\ �Y�Vr I o� SIZEBTU _��
�CT� MODEL:
�C'� MODEL:
_A/C $25.00 _FIREPLACE (GAS) $15.00
_AIR TO AIR EXCI�ANGEER $15 FIREPLACE (WOOD) $35.00
_BOILER $35.00 �^f�`URNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
DUCT WORK $10.00 _GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
_NEW GAS GRILL $10.00
GAS LTNIT HTR $10.00
_POOL HEATER $35.00
VENTILATOR $15.00
"` 'I�S IS A_N APPLIC ON 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 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 o a work i h r ' e review and a roval f plans. �--�l
���J V
SIGNATURE OF APPLIC P�AME II�� / l
DATE
AL
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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