P - 48475Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /i " !i
SITE ADDRESS _
THI5 APPLICANT IS:
PROPERTY
UWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-1-2012
YAUR
PHONE:
❑ OWNER
COMPANY NAME:_
CONTACTPERSON:
n.�
STATE LICENSE # EXP DATE _
ADDRESS: CITY
PHONE FAX
❑ SINGLE FAMILY ❑ TWO FAMILY
❑ NEW O REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
Permit No.:
Received By�,G�
Date R�� F�� 2 7
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TE ZIP.
ATE ZIP
FEES ARE BASED ON 510.00 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/BN
MFG: MODEL: SIZFJBN
IvIFG: MODEL: SIZElBTU
A/C $25.00 _FIREPLACE (GAS) $15.00 GAS RANGFJOVEN $10.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 _NEW GAS GRILL S10.00
_BOILER $35.00 _FURNACE 535.00 _GAS UNTI HTR $10.00
����HINlldEy LINER $10.00 —GAS DRYER $10.00 POOL HEATER $35.00
UCT WORK $10.00 GAS PIPING $10.00 %G`dENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
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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 ConsUvction Codes; that I understand this is
not a permit but only an applic 'on for a pe and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of rk whic eq ' es review and approval of plans.
SIGNANRE OF APPLICANT PRINT NAME�� j�s' n.� DATE� '–.`� �`o�I%��
APPROVAL
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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