P - 44931Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE I—��–�%
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
Permit No.:�
Received By:
����h�-
YOUR E-MAIL ADDRESS 1 pa le e�te C`� GI I'Y) Q/ i CLJYJ'�
OWNER ❑CONTRACTOR
ADDRESS:���� K
PHONE: (�DS I � �3� �
CITY
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: CITY
APPLICATION
PHONE FAX
PERMIT TYPE '� �1NGLE FAMILY ❑ TWO FAMILY p TOWNHOUSE
TYPE OF WORK• I� NEW ❑ REPLACEMENT ❑ ALTERATfON/REMODEL
DETAILED DESCRIPTION OF WORK ��y6`pyy� �(;�,�
ATB! //VZIP
ATE ZIP
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
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
A/C $25.00 FIREPLACE (GAS) $I5.00 GAS RANGElOVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY UNER $10.00 GAS DRYER $10:00 POOL HEATER $35.00
^DUCT WORK $] 0.00 _GAS PIPING $10.00 �VENTf LATOR $ I 5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of a�ll1work whi�requires review and approval of plans.
SIGNATURE OF
ALINSPECTORSSIGNA'
PRINT
v City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
DATE_ � — 2 �� �
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