P - 48246Building � �
Inspections
763-572-3604
763-502-4977 FAX
DATE I � � cJ1'— ( �
SITE ADDRESS � � � � �
THIS APPLICANT IS:
MECHANICAL
RESIDENTIAL APPLICATIO�N
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❑ OWNER
PROPERTY NAME:
OWNER/ ADDRESS:
TENANT,
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR �-MAIL ADDRESS
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�CONTRACTOR
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Permit No.:
Received
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COMPANY NAME:
CONTACTPERSON: ' ' � � C`��LI�!l%
STATE LICENSE # �RTH
ADDRESS: � MN 5�3
STATE ZIP
PHONE _ .FAX �
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: �� NEW �1 REPLACEMENT .
1 �
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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: � t:�:�i. MODEL: �� �G' SIZEBT[J ,� �} ��%
MFG: ���''��-� MODEL: 1.L �� �� L'�+� 1 SIZEBTU �� DC�C.�
MFG: MODEL SIZEBTU
� $25.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIR TO ATR EXCHANGFER � 15 F REPLACE (wOOD? 535.00 NEW GAS GRILL $10.00
BOILER $35.00 �URNACE $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
Number of fixtures @ $10.00 x $10.00 = $
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Numbez 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 = , $ 5.00
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rn�tiNiMUM FEE 540.001 Tota1= $ ' C�. �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L 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 applicati 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 �uoxJt�ich �r[P�s`i'evieuK and approval of plans.
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SIGNA7 URE (iF APPLICANT � �,
APPROVAL INSPECTORS SIGNATURE
PLEASE NOTE:
1'KINT
DA'
��' City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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