P - 44557Building
Inspections
763-572-3604
763-502-4977 FAX
DATE d � � 1 �
SITE ADDRESS
THIS APPLICANT IS: ,�!
PROPERTY NAME:�
OWNER/ pDDRESS
TENANT ,
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-20] ]
� �I. � YOUR E-MA]L ADDRESS
OWNER ❑CONTRACTOR
r�N � E'. a.. ,�
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #_
ADDRESS:
PHONE
FAX
CITY
EXP DATE ,
ClTY
PERMIT TYPE � SINGLE FAMILY ❑ TWO FAMILY �TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT �ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK 1 At
Permit No
Received Byy' Ul ��
Li'����N � ��
,p
STATF�ZIP
ATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WFIERE 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
MFG:
MODEL:
SIZE/B?U
MFG: MODEL: SIZE/BTU
,A/C $25.00 fitREPLACE (GAS) $15.00 ^GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $IS fiIREPLACE (WOOD) $35.00 NEi�V GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 _GAS UNIT HTR $10.00
�CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK $10.00 GAS PIPING $10.00 iVENTI LATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 rk w' req ' e review and approval of pl ns tL K�%� �/
SIGNATURE OF APPLICANT � � PRINT NAME r��IJI �—L..L} �Y�I'Z• /DqTE 3 2 I vZ�
APPROVALINSPECTORSSIGNATURE naTF
City of Fridley
B�ilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977 '