P - 47813Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-20] I
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❑ OWNER �CONTRACTOR
NAME: � S � f+f-
ADDRESS: CITY
PHONE: / 5�- 8'i.��"-+ ��
COMPANY NAME: e � � �
CONTACT PERSON: � (,r _ P��S- � (�.
Permit No.:
Received By: � I ►(�Uf�
Date{� c�: ►.,� � � � � �
ATE ZIp
STATE LICENSE # EXP DATE
ADDRESS:�OGJ �,,�� (�-r ��' CITY � //�j �r-
PHONE �y(a-„S y /�'�� FAX STAT6V���JZIPJ,�dy
PERMIT TYPE ��NGLE FAMILY O TWO FAMILY
TYPE OF WORK: � NE�' �I.REPLACEMENT
DET.
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❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAj�1 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: Y�t, f i1 o M�/7 �� �_,.u, �j
-r-==�r-���— MODEL: 1 // (j D SIZE/BTU �/��
MFG: MODEL:
MFG: MODEL:
A/C $25.00 FIREPLACE (GAS) $15.00
_AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
_BOILER $35.00 J.FURNACE $35.00
CHIMNEY LINER $10.00 !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 $15.00
_. ...« ,: x �.,;4 .�, � ,..,;
THIS IS AN APPLICAT[ON FOR A PERMIT-NOT VAL[D 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 per,mit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of ork hich equir s review and approval of plans.
SIGNATURE OF APPLICANT ' ^ PRINT NAME � V� i /o `' �_ �-
� �` DATE (�
APPROVALINSPECTORSSIGNATURE
�_�a-, T`, _. , �r.:-;,, : x��ar� _,�_.� �. ,,.. , ..,.. . _.. 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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