P - 47738Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
SITE ADDRESS _
THIS APPLICAN"t IS:
PROPERTY
OWNER/
TENANT
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YOUR E-MAIL ADDRESS ��/// / .
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CITY
Pernut No.: G.0 1'U v
Received By: � , �
Date ���� � ��
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STATE�ZIP
CONTRACTOR coMrarrY rraME: �% � 1 " c 1�7 � Gf �,/r- :1�1G� '� �i i I'� �a ,.T..r� c� •
SUBMIT A COPY OF CONTACT PERSON: o/��� LJ-L�
YOUR STATE STATE LICENSE # EXP DATE
LICENSEWITH ,�D�ss: /3�35' ��%�`�t .5�� �L�� CITY_ � t'� STATF/Lf/`�ZIP�J330
APPLICATION PHONE /(� 3�-7 �` CI �/ 7� Fn�c 7(�� 3�° �- 7 y-- ��i �,
PERMIT TYPE �''°�GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK' � NEW �EPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCI�IPTION OF WORK
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTEp. FIXTURES: (INDICATE TOTAL NIJMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
EquipmentInstalled MFG: � MODEL: ��ri/�(�R SIZEBTU ��n
MFG:
MODEL:
SIZEBTU
, � MFG: MODEL: SIZEBTU
VA/C 525.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
_.AIR TO AIR EXCIIANGEER $IS FIREPLACE (WOOD) $35.00 NEW GAS GffiLL $10.00
^BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
_CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK �10.00 GAS PIPING $10.00 VENTILATOR �15.00
Nwnber Of fixt�res @$ lO.Ot} x$10.0U =$
Number of fixtures @ $15.00 x $15.44 = $�
Number of fixtures a� $25.00 � x$25.00 =$�i �
Number of fixtures �a $35.Q0 x $35.Q4'= $
State Surcharge = $ S.OQ
(1VIINIMITM FEE $40.00} Total = $ " 7U , ��
THIS 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; tl�at 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 it and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work 'ch r uire� view and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME� / // �-11� /, �DATE__ � �QJ�/
APPROVAL
FLEASE NOTE: SEPARA'
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/� / City of Fridley
lBdilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977