P - 44373Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2010
DATE � �w. Z�': ._ � Q
SITE ADDRESS _��L
THIS APPLICANT IS:
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
Permit No.:
Received
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PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
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CONTRACTOR COMPANY NAME: � I�/ :�•
SUBMIT A COPY OF CONTACT PERSON: �-tEi D� z��S.-�Etil
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADD1tESS��2✓ Lc,�/�fO�I� /4�E`/�% CITY ���i�/ 141,..�,�'� STATL�"'[�ZIP C�'�
APPLICATION pHONE?�i3"��L�1l6(o FAX '7�� -�i-Z��fO��
PERMIT TYPE
TYPE OF WORK:
6� SINGLE FAMTLY O TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK I�U�.i4" L�1,,
❑ TOWNHOUSE
TERATION/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 Installed MFG: MODEL: SIZEBTU
MFG: ��� MODEL: L'�L �aO � � �O
MFG: MODEL: SIZEBTU
_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 FURNACE $35.00 GAS LJNIT HTR $10.00
�CHIMN�i' LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
�DUCT WORK $10.00 GAS PIPING $10.00 �VENTILATOR $15.00
Number of fixtures @ $10.00 x $10.0U = $ �
Number of fixtures @ $15.00 __�__ x $15.00 = $ � �� � '� � �'�'
��
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ .50
5"�
I hereby apply for a buildi
conformance with the or na�
not a permit but only appl
approved plan in the ase ofp�
SIGNATURE OF
AL INSPECTORS SIGNA'
_ � �� .�.
THIS IS AN APPLICAT[ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
nit and owledge that the information above is complete and accurate; that the work will be in
o s o e City of Fridley and with the Minnesota Construction Codes; that I understand this is
or a rmit nd work is not to start without a permit; that the work will be in accordance with the
� whic ` requir s review and approval of plans.
PRINT NAME L�/L� �U�Z-�.�A�I�DATE �' �+� '�E3
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977