P - 48153Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY NAME:�
OWNER/ qDDRES
TENANT
PHONE:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
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❑ OWNER �j,CONTRACTOR
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3: � � � ' CITY ,
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CONTRACTOR COMPANY NAME: S b
SUBMIT A COPY OF CONTACT PERSON: S
YOUR STATE STATE LICENSE # Di
LICENSE WITH ADDRESS:
APPLICATION pHONE -� (� 3 = �F�S �'J
PERMIT TYPE �NGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: O NEW �2EPLACEMENT
DETAILED DESCRIPTTON OF WORK
Permit No.:
Received By:
Date ���:�
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EXP DA'['E
_�_CITY _STA�'vZlP ��
FAX �(���� 5. '" CJ l.r
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU J 006 S 3RAE HANDBOOK. y�� n� ��,, �/�%�
Equipment Installed MFG: MODEL: �/ 1� ��i�� �y��J� SIZE/BTU �v
MFG: MODEL: SIZE/BTU
MFG: MODEL:
A/C $25.00 FTREPLACE (GAS) $15.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
_BOILER $35.00 �FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
DUCT WORK $]0.00 GAS PIPING $10.00
StZE/BTU
GAS RANGE/OVEN $10.00
_NEW GAS GRILL $]0.00
_GAS UNIT HTR $10.00
POOL HEATER $35.00
_VENTILATOR S 15.00
THIS IS AN APPLICA7'ION 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 ord'nances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an p li ti a ermit an work is not to start without a permit; that the work will be in accordance with the
approved plan in the cas of ( ic requir eview and approval of I s.
SIGNATURE OF APPLICAN PRINT NAM��"' �� s�'`-� DATE I���` ��
APPROVAL
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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