P - 44921Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE `� °(�- 1 �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL
❑ OWNER �CONTRACTOR
Permit No.:"LQ
Received By: �
��e0��
�Y�r1YlPr�-h,�'� ,
NAME: �
ADDRESS: 2 �� C CITY STA ZIPi��i�Z
PHONE: � (O� - `J� � - Z Z Z�j
Co1v1P.ANYN.4ME: -�YleY�j�.� UYI� i-k�u,'�--
CONTACT PERSON:
STATE LICENSE #'C3Y1 �l e- E ATE - yy�,l
ADDRESS:yU2I ��{P CITY (�(]l,`mo ;lA STATEI�►1VZIPS�Q7j
PHONE l �Q �- ?j��j-% c� �_ FAX
�SINGLE FAMILY ❑ TWO FAMILY
� NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
� ALTERAT'ION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVf�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK \`
Equipment Installed MFG: LC� MODEL: ��� fISV SIZEBTU
MFG: MODEL: SIZEBTU
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
_BOII.ER $35.00 _FURNACE $35.00 _GAS LTNIT 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
THIS IS 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 application for a ermit and �rk is not to start without a permit; that the work will be in accordance with the
approved plan in the case ofrajYwo�lc whiy�h quirp.�s��iew and approval of plans. �
SIGNATURE OF
ATURE
i�
�
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977