P - 45099Building MECHANICAL
Inspections RESIDENTIAL APPLICATI�N
�63-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-20] I
DATE_�_�
SITE ADDRESS �
THIS APPL]CANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
i
❑ OWNER
NAME:
ADDRESS:
PHONfi:
COMPANY NAME:_
CONTACTPERSON:
STATE LICENSE #
ADDRESS: ��
PHONE � (r?�j L/
YOUR E-MAIL ADDRF.SS
�tNGLE FAMILY � TWO FAMILY
❑ NEW �REPLACEMENT
DETAILED DESCRIPTION OF WORK
Permit No.:
Received By: ��_
��e T' t'�t,��—����
CITY
t1�C<�V�- �!�' �--'�i ��if'S �``� �
EXP DATE
'��G` CITY �'�"{jt ��j��{'i
FAX � �C � �� � `7 ���
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
����� � r� 9 �� �
STATE_ZIP
ATE�/1ZIP ��1�
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NQTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL 2006 ASHRAE HANDBOO]C.
Equipment [nstalled MFG: j MODEL: ��a��"Z���� a�
SfZE/BTU �1 O�
MFG: , ?u � MODEL: � �rJ�/�''��Z� SIZE/BTU �
MFG: MODEL:
A/C $25.00 FJREPLACE (GAS) $15.00
�AIR TO AIR EXCHANGEER $15 ,FIREPLACB (WOOD) $35.Q0
'BOILER $35.D0 FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
_DUCT WORK $10.00 �GAS PIPING $i0.00
SIZEJB�"U
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $ I 5.00
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 not to start without a permit; that the work will be in accordance with the
approved plan in the case of al] work which re � s review and approval of plans.
� L!/ 7 / /
SIGNATURE OF APPLICANT ~'�� v" PRINT NAME r `I DATE ,
APPROVALINSPECTORSSIGNATURE DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977