P - 44983Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS �;
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
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ADDRESS:
YOUR E-M�IL
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❑CONTRACTOR
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Permit No.:
Received By:
Date R '
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h� 9r,��N �= Ca/r�-CCS�`- /2 �J
�,vi� i nri� i vic COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE L]CENSE # EXP DA1"E
LICENSE WITH ADDRESS: CITY
APPLICATION
PHONE _ FAX
PERMIT TYPE
TYPE OF WORK:
�INGLE FAMILY ❑ TWO FAMILY
❑ NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK dA�
❑ TOWNHOUSE
�ALTERATION/REMODEL
ATE �NZIP JS��
ATE ZIP.
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL NUMBER OF EACN BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZE/BTU
_A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
_DUCT WO�(C $ ] 0.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $I5.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
_GAS PIPING $10.00
S[ZE/BTU
SIZE/BTU
_GAS RANGE/OVEN $10.00
NEW GAS GRILL$10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
�VENT►LATOR $15.00
THIS IS AN APPL[CATION 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 an application for a permit 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 ork which re uires review and approval of plans.
SIGNATURE OF APPLICANT �RINT NAME ���� `�"��I°�' '�'� � ���`'"q���' � �,� �'��'' � � �
APPROVAL[NSPECTORSSIGNATURE naTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977