P - 44976Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE F %'"' � V "I .
SI7'E ADDRESS �I
THIS APPLICANT IS:
PROPERTY
OWIVER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
R E-MAIL ADDRESS
❑ OWNER
ADDRESS:_ CQ J�+�
COMPANY NAME: �
CONTACT PERSON:
STATE LICENSE # Z d%
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PHONE%� 3 �Gr /,�0� FAX
PERMIT TYPE SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
IV�.- CIT1'�
EXP pATE �CJ� —
CITY
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❑ TOWNHOUSE
1L� aLTERATiON/REMODEL
Permit No.:
Received By: �
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Dat��' � � � o � � �
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STAT�.-�� ZIP� �3
FEES ARE BASED ON $10.00 PE12 FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL IVUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: ,_ _ MODEL: SIZE/BTU
MFG: G� MODEL: 17.� SIZE/BTU _�o �
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
AIR TO AIR EXCHANGEER $15 �FIREPLACE (WOOD) $35.00
�BOILER $35.00 FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
_DUCT WORK $]0.00 GAS PIPING $10.00
SIZFJBTU
GAS RANGE/OVEN $I0.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
_V ENTiLATOR $15.00
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; that the work will be in
conformance with the ordinances and codes of the City of Frid(ey 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 w rk � ich �rires �approval of plans.
f ,/�j� r
SIGNATURE OF APPLICANT o 4!r PRINT NAME �(�� �'���� ~t �� pATE ����� ^//
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley'
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977