P - 45684Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I��� O� � � I
SITE ADDRESS �
THIS APPLICANT [S:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] 1
YOUR E-MAIL ADDRESS
❑ OWNER �1 ONTRACTOR
NAME: �J
ADDRESS: � �� ,�j �, \}0�,�('I�
PHONE: � p�` —��=I)`G��
COMPANY NAME:
CONTACT PERSON:
Permit No.: °.��
Received By:� �
D�C����:C T 2
ATE ZIP,
STATE LICENSE # -�—}—� EXP DATE
ADDRESS: i,��� `\y� (Q�h �'r" N� CITY ���_STATE �' IIG�P SS
PHONE f ����`�' � � �_ FAX
PERMIT TYPE �INGLE FAMILY � TWO FAMILY
TYPE OF WORK: � NEW `�ZEPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK ���� �� Q �'� ��(�,
. _________�
FEES ARE BASED ON $10.00 FER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAJ, J� 2Q0( ASHRAE HANDBOOK. �7 -�j��� A-p� �,`
Equipment Installed MFG: ��,w (�\ MODEL: (�-� N V l L.`fl'"` V g1iE/BTU __��-I U
MFG:
MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
_AIR TO AIR EXCHANGEER $15 IREPLACE (WOOD) $35.00
_BOiLER $35.00 �URNACE $35.00
CHIMNEY LINER $10.00 T GAS DRYER $10.00
_DUCT WORK $10.00 GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
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 APPLICAT[ON FOR A PERMIT-NOT VALID CINTIL 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 es of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applic on 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 I wo which require view ar�d approval of plans.
SIGNATURE OF APPLICANT ' ���� DATE � o���j"� I�
�.
ME �1�f' � � 1�"
APPROVAL
����1
C_���P�ity of Fridley
Buildin nspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977