P - 48219Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE ]-1-2011
DATE
SiTE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATTON
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL
❑CONTRACTOR
NAME:
PHONE: 7�0 3�Da `� 33 �
COMPANY NAME:
CONTACTPERSON:
STATE LICENSE #_
ADDRESS:
PHONE
SINGLE FAMILY
O TWO FAMILY
FAX
Yl � ct� � ricP f �
G
EXP DATE
CiTY
❑ TOWNHOUSE
❑ REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK
�
Permit No.:
Received By:�_
r
Date Rec'd:
���I 1 � � ���
ATF�i ZIP 5sy32
A7'E ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: ([NDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Instailed MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
_A/C $25.00 FTREPLACE (GAS) $I5.00 _GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 _GAS UNIT HTR $10.00
C EY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
UCT WORK $10.00 _GAS PIPING $10.00 _VEN7'ILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL 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 w(ic re uires review and approval of plans.
SIGNATUREOFAPPLICAN � PRINTNAM _E � UL VC%�ru�� DATE j�/�� ��
APPROVALINSPECTORSSIGNATURE naTF
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977