P - 48346�uilding MECHANICAL Permit No.• / -
Inspections RESIDENTIAL APPLICATION �+i� �
l, UiV�:��
763-572-3604 CITY OF FRIDLEY ate xec'c1:
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE � I YOUR E-MAIL ADDRESS
SITE ADDRESS ��3 ���T, �M�✓ �1 G�-�'�r i��
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY NAME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR COMPANY NAME: �`�
SUBMIT A COPY OF CONTACT PERSON: �� � `' I"` �y
YOUR STATE STATE LICENSE # n EXP DATE
LICENSE WITH ADDRESS:I i� (�� 1��,if �fi:. N� CITY � 1(,l.Y �L �+ �1� STATE �ZIPLa��� I
APPLICATION pHONE 1 � " �irC� '" `c'7i; �l � FAX
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEW ❑ REPLACEMENT �ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK�.�M1��:�� 1 ���^ � Ut/� � 1� I 1I L'�"�'lr�' ` 1�'t ��' d'+=� �����_
c`�.i �ris �`v� � s� k'.1� h �1�"�'w�.
�J
FEES ARE BASED ON 510.00 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: SIZEBTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 _FIREPLACE (GAS) $t5.00 GAS RANGE/OVEN $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
_CNIMNEY LINER $10.00 GAS DRYER $10.00 �OOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $]0.00 VENTILATOR $15.00
Number of fixtures @ $10.00 x $10.00 = $
r � �.�
Number of fixtures @ $15.00 Y x $15.00 = $ '� �
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ 5.00
°g� U'�
MINIMUM FEE $40.00 Total = $ � U `'
TFiIS 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 applicatio �,permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the ase of rk whic uires review and approval of plans.
SIGNATURE OF APPLI ANT �' .V `� PRINT NAME � �' ""'� �� DATE�� � �
� � �. 'r
APPROVAL INSPECI'ORS SIGNATURE � DATE
PLEASE NOTE: SEPARATE PERMITS � RE UI D FOR BUILDING, ELECT AL D MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977