P - 48624Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�Z �`i-��Z
SITE ADDRESS l �� � ^T�
THI3 APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMTT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-i-2012
ADDRESS:
�
COMPANY NAME:_
CONTACTPERSON:
YOUR E-MAIL ADDRESS
�CONTRACTOR
STATE LICENSE # EXP DATE _
ADDRESS: CITY
PHONE FAX
� SINGLE FANIILY 0 TWO FAMILY
❑ NEW �IREPLACEMENT
DETAILED DESCRIPTION OF
�ti�«�� 0. G�� ��
�
�
C�TOWNHOUSE
c'
C�ALTERATION/REMODEL
i��il A/IG�D / rll�P w n tn� i
e
Permit No.:'P� V' 1/(��
Received By:��,��
DREC'Dc����
iNLG�t %�TK.
STATE IM�ZIP -�iS U�
'ATE ZIP
FEES ARE BASEb ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUA J 2� U�0�6 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZFIBN
MFG: G � MODEL: SIZFJBN
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
_CHININEY LINER $10.00 GAS DRYER 510.00
DUCT WORK 510.00 �GAS PIPING $10.00
SIZElBTU
�GAS RANGFJOVEN $10.00
NEW GAS GRILL $10.00
GAS LTNIT HTR S 10.00
POOL HEAT'ER 535.00
�VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 nnt to start without a permit; that the work will be in accordance with the
approved plan in the case of a11 work which requires review and approval of plans.
SIGNATURE OF APPLICANT ��� PRiNT NAME el� c�-.` C-In,Y�I I'� DATE �-� ��� 2�[ �
APPROVAL INSPECTORS SIGNATURE _ __ DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977