P - 45087Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX FFFECTIVE 7-t-2010
DATE � Z
SITE AD RESS _
THIS APPLICANT I3
PROPERTY
OWNER/
TENANT
l(� YOUR E-MAIL ADDRESS ��'��___� ��i
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�OWNER ❑CONTRACTOR
NAME: � � t� -
ADDRESS: ( CF� /c_�f�I/'� / / �AJ� N�-% C1TY��=?�'��_L_
PHONE: �� ?i � , l E> �- _ CiCi'� � ! �.:� � � 52' �'� J
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE #
LICENSE WITH ADDRESS:
APPLICATIQN pHONE
PERMIT TYPE �NGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: � NEW D REPLACEMENT
DETAILED DESCRIPTION O� WORK
EXP DATE
CITY
FAX
O TOWNHOUSE
�ALTERATION/REMODEL
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Permit No.:�IU'U��-{ �f �
Received By: '�
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STAT�!1�ZIP.�S S�vc
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STATE ZIP
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FEES ARE BASED ON $10.00 PER EIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOS5 CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Eqarpment InstaVled MFG: MODEL: SIZE/BTU
A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
^CHIMNEY LINER $10.00
i /ISUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
�FIREPLACE (WOOD) $35.00
UKNACE $35.00
GAS DRYER $]0.00r n
GAS PIPING $] 0.00 ( b+'t P��i �'1Z�
SiZE/BTU
SIZEBTU
`GAS RANGElOVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $]0.00
POOL HEATER $35.00
VENTILATOR $15.00
�__.___--�-~"' THIS IS AN APPLiCATION FOR A PERMIT-NOT VAL1D 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 siart without a permit; that the work will be in accordance with the
approved plan in the case of all work�vhich requires review and approval of plans. ' �
SIGNATURE O� APPLICANT �� � PRINT NAM���C C'����5� AATE (� ��� (�
APPROVAL INSPECTORS SIGNATURE _ _ _ _ . DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977