P - 37487Building
Inspections
763-572-3604
7b3-502-4977 FAX
DATEO ll
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
NAME:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFF$CTIVE 1-1-2011
YOUR E-MAIL ADDRESS
IJ� V /^ e : s
❑ OWNER �ONTRACTOR
CITY
PHONE:�P� ?� C,% (� I Z 2
COMPANY NAME: i � 1__�
CONTACTPERSON:
i�
Permit No.:
Received By;
Date �c�'q�
�c u
STATE�`) ZIP
STATE LICENSE # EXP DATE
ADDRESS: �c�5, � �•°�a'1'+�"�� {�,� CITY !� �'��I`C.� �STATE rn� ZIP ��3
PHONE_ 7� 3!��``� J'%I U FAX
�SINGLE FAMILY ❑ TWO FAMILY
,�NEW ,�REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
Q ALTERATION/REMODEL
�C�-
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK. ���+ �! ��
Equipment [nstalled MFG: Sn,.�{/.�k,.{YAqODEL: �� �Q SIZE/BTU � ��
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 ISFURNACE $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 VENTILATOR $15.00
THIS 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 rk which requires review and approval of plans. �
SIGNATURE OF APPLICANT PRINT NAME (\��� W��CX� DATE v/�� �'
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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