P - 44200Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE2-19-09
DATE � � — �'I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
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COMPANY NAME:,�
CONTACT PERSON:
STATE LICENSE #_
ADDRES �
PHONE�Ia 3�
SINGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
OF WORK
`JEXP DATE
i�_CITY
FAX
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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Permit No
Received By!
Date�'�: a�
STATE Z[P.
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURESc (INDICATE TOTAL NUMBER OF EACH BELOW)
Equipment Installed MFG: MODEL: S1ZE/BTU
_A/C $25.00
AIR TO AIR EXCHANGEER S 15
_BOILER $35.00
CHIMI�iEY LINER $10.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
�GAS DRYER $10.00
GAS PIPING $10.00
SIZE/$TU
SIZE/BTU
GAS RANGE/OVEN $]0.00
NEW GAS GRILL 510.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
�VENTILATOR SI5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pennit and I acknowledge that the information above is complete and accurate; that the work will be in
confonnance 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 ork which requir review and approval of plans. �
SIGNATURE OF APPLICANT � PRINT NAME � �--! � 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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