P - 84367Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE 1-1-2012
DATE�_
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY
OWNER/
TENANT
�-- YOUR E-MAIL ADDRESS
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❑ OWNER �CONTRACTOR
NAME:��� � � i �
ADDRESS: �% j�} j/�_._�
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Permit N
Received By:l r �' �
DatT��C�� � � � I�
ATE ZIP
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON: p.�4�'+ �' �,^ ^� F'
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YOURSTATE STATELICENSE# (r��� t,�,���� ����Cp�A,'�fi" s ,
LICENSE WITH � `° "�
ADDRESS: �^ e°d�ea CITY STATE ZIP
APPLICATION pHONE � FAX � r�
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PERMTT TYPE
Y��/����,ti��L1a �is�i
DETAILED
�SINGLE FAMILY ❑ TWO FAMILY
i
❑ NEW �`E] REPLACEMENT
OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZEBTU
MFG: ��� MODEL: �.�.�'�(.1 � �/`i /b'I�B�f�T / V� U d �
_A/C $25.00
_AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG: MODEL:
FIREPLACE (GAS) $I5.00
FIREPLACE (WOOD) $35.00
�FURNACE $35.00
_GAS DRYER $10.00
GAS PIPING $10.00
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS LJNIT HTR $ ] 0.00
_POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 applieation for a permit and work is not to start without a permit; that the work will be in accardance with the
approved plan in the case of all wark which re�ires review and ap�roval of plans; � �
SIGNATURE OF APPLICANT
APPROVAL INSPECTORS SIGNATURE
DATE
l� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432 .
763-572-3604 FAX: 763-502-4977