P - 44112Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502�4977 FAX EFFECTIVE 1-1-2011
DATE < �-'
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
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SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
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❑ OWNER
YOUR E-MAIL ADDRESS
F! i � /iU
.�ONTRACTOR
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Permit No.:
Received By;�i_ �'�
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ADDRESS: ��'/ G I M4 ��� S f N� CiTY I/`; c( I'�y STATI-l%^�LIP S�/ a
PHONE: d-c.���y o s
COMPANY NAME: � aI r r L
CONTACT PERSON: ;,�, q �
STATE LICENSE # EXP DATE
ADDRESS:_ � 7� �ai�{ S� S� CITY � v�C�, �0 STA��z�r 55 -�i.�
PHONE %�n ,3 -.�v 5��� O/ 3�o FAX
PERMIT TYPE � S�ivGt,E FAtvt�LY .�rWO FAMILY
TYPE OF WORK: � NEW ,�{tEPLACEMENT
DETAILED DESCRII'TION OF V1�ORK
❑ TOWNHOUSE
❑ ALTERATIONlREMODEL
FEES ARE BASED ON $]0.00 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: SIZE/BTU
A/C $25.00
`AIR TO A[R 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
�URNACE $35.00
GAS DRYER$10,00
GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
_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 appty 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 ptan in the case of all wo k� ich require���iew and approval of plans.
SIGNATURE OF APPLICANT Gt, � PRINT NAME ���4j� : / �f'/ ��.� � DATE / � �
TURE
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977