P - 37250Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATI
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
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THIS APPLICANI' IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBNIIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
NAME: N��CIi
ADDRESS: ���
rxorrE: Csz ia- `! b a-1d.\ 5
CITY �iC�J'bJE�/ STA �T�%LZIP�'�
coMr.�vY rraME: �'r A m �'� ��. A N t c a�. � T,n r
CONTACT PER30N: ��ti k E �_t�� LSGYvi
STATE LICENSE # EXP DATE
ann�ss: 35-08 �n1 ���+.� G, /��f. ,� crrY %}'% PC S STATE /'l�IP .�' IOsp
PHONE a 1�. '� a� - J�o'�f lP FAX �IL 1�c.' �]�� " CD (Q S�{
�INGLE FAMILY ❑ TWO FAMILY
❑ NEW �EPLACEMENT
DETAILED DESCRIF'TION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
0
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTEA FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi�
PROVIDE HEAT LOSS CALC'S PER MANUAL 2006 SHRAE HANDBOOK
Equipmeut Installed MFG: �i �► � MODEL: Jr g� SIZE/BTU �
_ MFG:
MFG:
_A/C $25.00
AIR TO AIK EXCHANGEER $15
�BOILER $35.0(?
_CHIIvI13EY LINER $10.00
DUCT WORK $10.00
MODEL:
MODEL:
FIREPLACE (GAS) $15.00
�FIREPLACE (WOOD) $35.00
_FURNACE $35.00
_GAS DRYER $10.00
GAS PIPING $10.00
SIZEBTU ,
SIZEBTU
_GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS IJNTT H112 $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID i7N'I'IL 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 ardinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a pernut but only an application for a pernut and work is iuot to start without a pernut; that the work will be in accondance with-ti�e
approved plan in the case of all work wl�ieh requires rey�iew and approval of plans.
SIGNATURE OF APPLICANT
APPROVAL INSPECTORS SIGNATURE
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DA
City of Fridley
Buiiding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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