P - 47807Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX
EFFECTIVE 1-1-2011
DATE �"� Z� � l YOUR E-MAIL ADDRES S 1Ti�v��,�'cS f3%11�. � G
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYpE
TYPE OF WORK:
❑ OWNER ❑CONTRACTOR
-3 �'�– 6' 2 �",
COMI'ANY NAME:�
CONTACT PERSON:
STATE LICENSE #
,_.
EXP DATE
Permit No.
Received
Date �e#�: • I���
ar�iL��SS
�`INGLE FAMILY ❑ TWO FAMILY ❑ TOWNFIOUSE
� ��' ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
J�ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NiJMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK
Equipment Installed MFG: MODEL: 5���
MFG:
MODEL: 5���
MFG: MODEL: SIZEBTU
_A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 _FURNACE $35.00 _GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
UCT WORK $10.00 GAS PIPING $10 00 VENTII,ATOR $15 00
Number of fixtures @ $10.00 x $10.00 = $
Number of fiactures @ $15.00 x $15.00 = $
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ 5.00
�
_�muruviulvl r'�� �40.00) Total = $ `7 V "
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appiy 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 work whi requires review and approval of plans.
SIGNATURE OF APPLICAN'T PRIIV'I' N ,r c��lJ DATE �� �� �'
APPROVAL INSPECTORS SIGNATURE DATE
PLEASE NOTE: SEPARATE pERMITS ARE REQUIItED FOR BUII,DING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-36Q4 FAX: 763-502-4977
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