P - 48186Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2012
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SITE ADDRESS _
1'HIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
�OWNER
YOUR E-MAIL ADDRESS �
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❑CONTRACTOR
Permit No.:
Received By
ADDRESS: � �L� �� CITY STATE ZIP
PHONE: sat — ,���f 3 .
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE # EXP DATE
ADDRESS: CITY STATE ZIP
PHONE FAX
TYPE OF WORK: I O NEW
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
❑ REPLACEMENT �1LTERATION/REMODEL
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER (� EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
_A/C $25.00 �.,� _FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $]0.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 _FURNACE $35.00 _GAS UNIT HTR S 10.00
CHIA�INEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
�DUCT WORK $]0.00 _GAS PIPING �10.'D0. VENTILATOR $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 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 wor which requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME C17 ���/ ��fi'�-�'�'y DATE / (�
APPROVAL IlVSPECTORS SIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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