P - 44926�
Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
m
E-MAIL ADDRESS
.� � �
❑ OWNER �ONTRACTOR
ADDRESS: � y� Z I�.LLr v i Y+.�v %,P."L-�rr CITY
PHONE:
Permit N
Received By:
Date Rec'd:
STATFI�ZIP
CONTRACTOR COMPANY NAME: �;�t t rL d rN /!T 4vt��_ �L. /
SUBMIT A COPY OF CONTACT PERSON: �C�� /7 Li^C,SCt7
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WTTH ,�DRESS: ���/ l/(�CtI� S/ CITY Qt STATH�/f�ZIP S�d
APPLICATION pHONE � � � "' %�/2 �p � � FAX %( �?�( 3 - o� d
PERMIT TYPE
TYPE OF WORK:
DET.
�INGLE FAMILY ❑ TWO FAMILY
❑ NEW � REPLACEMENT
OF WORK
❑ TOWNHOUSE
"�1LTERATION/REMODEL
�
Pf .- �'^lliP n�Qt� _ �
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV4�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed w/� MFG: MODEL: SIZEBTU
� �i
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 �FIREPLACE (GAS) $15.00 iCGAS�RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $IS _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35 GAS LJNIT HTR $]0.00
CHIMNEY LINER $10.00 GA $10� 0 POOL HEATER $35.00
�DUCT WORK $10.00 � r� AS PIPIN VENTILATOR $15.00
THIS IS AN AFPLICATION FOR A PEKMIT-NOT VALID UNTIL PROCESSED
I hereby apply far 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 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 w k i h requires review an pproval of plans.
SIGNATURE OF APPLICANT y _ , PRINT I�T�vIE �1'i�� � 11 L �*T S�'YlJ DATE ~I '�
AL
DA
City of Fridley
Buil ing Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
�