P - 48097Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE i-i-zo�i
nA� v •
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERNIIT TYPE
TYPE OF WORK:
❑ OWNER
NAME:
ADDRESS: �
PHONE: � �
1
COMPANY NAME:
CONTACT PERSON.
sTa� LicErrsE #
�D�SS:i
PHONE LI
E-MAIL ADDRESS
FAX
DATE
L�INGLE FAMILY ❑ TWO FAMILY -._ ❑ TOWNHOUSE
.� ,
❑' NEW �REPLACEMENT O ALTERAT[ONfREMODEL
DETAILED DESCRIl'TION OF WORK
Permit No.
Received By:
Date
A'I'� ► U �ZIP
FEES ARE BASED ON 510.011 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOR�
PROVIDE HEAT LOSS CALC'S PER MANUA� L,�IT 1�HItAE HANDBOOR ✓�(�(� (�
Equipmetrt Installed MFG: � MODEL: ��� /I Ul U� SIZFIBTU �S.L
; MFG: MODEL: SIZEIBTU
_ MFG: MODEL: SIZEBTU _
_A!C $25.00 _FIREPLACE (GAS) $15_00 _GAS RANGEIOVEN �10.00
AIR TO AIR EXCifANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL �10.00
BOII.ER 535.0(1 ( XFURNACE 535.00 GAS UNIT HTR $10:00
CHININEY LINER $10.00 GAS DRYER S 10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VEN'ITI.ATOR $15.00
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(l1�fill�ill'I[Tl� �ET $40«ItU� TOtat ='$ �` �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appiy for a building permit and I aclrnowledge 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 pian in the case of a11 rk w c w and approval of plans.
SIGNATURE OF APPLICANTt� .a�X/C _ PRII�NAME J�1 /I� /� d,J �[' /C�lrLQA-TE � /�C�/� U / �
APPROVAL INSPECTORS SIGNATURE
City of Fridley
ilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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