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Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTivE �-i-zo�z
Permit No.
Received By:
DATE �" �' �� YO�U�R E-MAIL ADDRESS
STI'E ADDRESS �� ✓� ��':I, � � �/�' �•
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY NAME: 1% G
OWNER/ ADDRESS: � � NG� CITY �I' 1(� I-e�,/ STATE ��IPSSU 3�
TENANT ,,,.�_,.. n j „� . �`I �Cn _ _ �'IU �'
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
• APPLICATION
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COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #
'�IN l �
���� �
E� DATE 1 a-3 I- i�
rG� e CITY 5 hr,�kCOee STATH—��.1 ZIP 55t38�
FAX
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � �W REPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK t�ecc�nn��ed q C1.5 G�,YV f
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'5 PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZEBTU
A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
_DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
_GAS PiPING $10.00
SIZEBTU
SIZEBTCT
GAS RANGE/OVEN $10.00
_NEW GAS GRILL $10.00
GAS LJNIT HTR $10.00
POOL HEATER $35.00
_VENTILATOR $I5.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 work which r quires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAMEsarn��e R�o� i DATE �'�� ��(�
APPROVAL INSPECTORS SIGNATiJRE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977