P - 45471Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECT�vE �-�-20> >
DATE -- � � —
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR E-MA]L ADDRESS
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❑ OWNER �CONTRACTOR
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NAME: [ ��i � EV'��;,0�..- �
ADDRESS:� �ti jF`� —� CITY.
PHONE:
COMPANY NAME: -�' �✓� j
CONTACT PERSON: �"
STATE UCENSE #
ADDRESS:7i I�� ;-�.¢f�
vunT.t � � �i iCl � �c't1 C9
�INGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK <�I�l�
EXPDATE
G IS'ta JC � t TCI Y (�•:
FAX � ? iC � �'_ ( (
❑ TOWNHOUSE
@ALTERATION/REMODEL
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Permit No.:`L.U� ��� j,j Z.�
Received By:•�
Dat �, l�d: • � ` `� � � �
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STATE Z[P
STAT�ZIP S�� �
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: SIZE/BTU
A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $ ] 0.00
MFG: MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FTREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZElBN
SIZE/BTU
GAS RANGE/OVEN $10,00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTI LATOR $15.00
THIS IS AN APPLICAT[ON FOR A PERM[T-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 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 wo w'ch requires review and approval of pla s.
SIGNANRE OF APPLICANT PRINT NAM��� ��'�� `� ��°vDATE�'� — I
APPROV.
TURE
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977