P - 47959Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX
_ EFFECTIVE 1-1-2011
Permit No.:
Received By:
Date ��
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DATE /�_�' YOUR E-MAIL ADDRESS �G r,,�2� q 3��,��•(„ �„yt
SITE ADDRESS d r� Je�.-tb N pR �
THIS APPLICANT IS: '�OWNER ❑CONTRACTOR
PROPERTY NAME: SS
OWNER/ ADDRESS: �0�� Ci OIIQQTO� �1� CITY t,,�
TENANT STATE//I ZIP SSy.�,
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CONTRACTOR COMPANY NAME:��
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS:
APPLICATION CITY
PHONE FAX
PERMIT TYPE �NGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK:
❑ REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �7�1 ����„/�ji �,� �/�
STATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL IVUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL:
MFG: MODEL:
_A/C $25.00 FIREPLACE (GAS) $ I5.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
_BOILER $35.00 FURNACE $35.00
_CHIMNEY LINER $10.00 GAS DRYER $10.00
DUCT WORK $]0.00 _GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
_GAS RANGE/OVEN $10.00
NEW GAS GWLL $10.00
_GAS UNIT HTR $10.00
POOL HEATER $35.00
�V ENTI LATOR $15.00
THIS 145 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 appl' ion 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 o all rk whi�h reyuires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME AI: S�OLJCSI DATE "—1
APPROVALINSPECTORSSI�NATURE DATE
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City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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