P - 36952Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��/ �
SITE ADDRESS �(
THIS APPLICAI3T IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE I-1-2011
YOUR E-MAIL ADDRESS
❑ OWNBR
Permit No.:
Received B ! � 1'qi'� �
��e���' � �
ADDRESS: J '� .. W CITX �' T�I�_ STATE�NZIR_SS��j2-
pxo : - S-4�
COMI'ANY NAME: �
CONTACT PERSON: Ia
STATE LICENSE # E DATE p
ADDRESS:I�ag ���7�.�7,� V jD� ��y CITY /`� �TATE a/NL'IP,��
PHONE ��'�� 1�LJ �11 F�
PERMIT TYPE f'��GLE FAMILY ❑ TWO FAMILY
TYPE OF W4RK: � �`� �PLACEMENT
�
DETAILEI2 DESCRIPTION OF WORK � �
❑ TOWNHQUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WFiERE NOTED. FIXTURES: (INDICATE TOTAL Nii7MBER OF EACH BELOV�
� OVIDE �ATe�LOSS CALC'S PER �GU L J 20�e �� A 6�jH�R�A�" HANDBOO MODEL: �`�� �' I N UU� SiZEBTU eQ •�J1�1
�7 -.,__�_ .
MFG: MODEL: SIZFJBTU
pv(FG: MODEL: SIZE/BTU
A/C $25.00 lFIREPLACE (GAS) $15.00 ,GAS RAIVGEJOVEN $10.00
_ATR TO AIR EXCHANGEER $15 XREPLACE (WOOA) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 �t3RNACE $35.00 _GAS UNIT HTR $10.00
CI-ffivINEY LINER $10.00 _GAS DRYEIt $10.00 ,POOL HEATER $35.00
DUCT WORK $10.00 GA5 PIPING $10.00 VENTII.ATOR $15.00
Number of fixtures @ $10.00 . x $10.00 = $
Number of fjxtures @ $15:00 x $15:00 = $
Number of fixtures @ �25.00 x $25:00 = $ '
Number of fixtures @ $35.00 � : x $35:00 = ��
State Surcharge = $ ' S:00
Q17[INIMUM FEE S40.OQ) Total = $ � �,.��� _
THIS IS AN APPLICATIOI3 FOR A PERNIIT-NOT VALID UNTIL PROCESSEA
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 pernnit but only an application for a p 't and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of a11 wor ic uire review and approval of plans.
SIGNATURE OF APPLICANT Y � �'�IT NAME ����^ L� DATE /
�.:: G i
APPROVAL INSPECTORS SIGNATU DATE
PLEASE NOTE: SEPARATE .ARE REQIJIRED FOR BUII.DING, BLECTRIC AND MECHANTCAL WORK
� City of Fridley
Building Inspections Department
b431 University Avenue NE, Fridley, NIN 55432
763-572-3604 FAX: '763-502-4977