P - 48228' Building
+ Inspections
763-572-3604
763-502-4977 FAX
DATE ��i � � � I
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
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❑ OWNER ONTRACTOR
v I�av� N: ol S
i: (o dSS 1 vl C-I�—ILl �� 1�� CITY
L�-s��-�ybo �
COMPANY NAME:
CONTACTPERSON:
STATE LICENSE #
PHONE �
�J SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �REPLACEMENT
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EXP DATE
S
Permit No.:
Received By: li `�°i�
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CITY �Y� STATL�N ZIP��,�I
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❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK P� � a�f.L- ��- �
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANU J 2�RAE HANDBOOK 12L �d �
Equipment Installed MFG: MODEL: l�!/V � SIZE/BTU ,Z' S"1 b N
MFG: MODEL: SIZEBTU
� A/C $25.00
AIR TO AIIt 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 PIPING $10.00
�l�{ili1VY1��V1�11A1.U1VJ:`W �iV.VV ��:A �1V.VV - �
Number of fixtures @ $15.00 x $15.00 = $ `
Number of fixtures @$25.00 �` x$25.00 =$ ZS . v0
Number of fixtures @ $35.00 x $35.00 = $ '
State Surchazge = $ 5.00
(MINIMUM FEE $40.00) Tota1= $ � � �' �
SIZE/BTU
_GAS RANGE/OVEN $10.00
_NEW GAS GRILL $10.00
GAS iJNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
TffiS 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 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 all work equ�res view and approval of plans.
SIGNATURE OF APPLICANT lvGY`���/ V�1��� PRINT NAME IN �i41� � QW��- IDATE ( ZI I 6 I( I
APPROVALINSPECTORS
PLEASE NOTE: S
City of Fridley
ilding Inspections Department
1 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977