P - 42164Building MECHANICAL
Inspections COMMERCIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTNE 1-]-2011
DATE___�
S(TE ADD E �
THIS APPLICANT IS:
PROPERTY
OWNERI
TENANT
❑ OWNER
YOUR E-MA[L ADDRESS
�CONTRACTOR �OARCHITECT/ENGINEER
����G�
Permit No.:
Received By:
Date Rec'd:.3 �" � �
CITY�%P �S��P/ STATE II'�Z[P OO
CELL: �A? c.._°.. FAX:
CONTRACTOR COMPANY NAME: e � �jl "
NOTE: CONTACT PERSON: %_
SEPARATE CITY STATE BOND # EXP DATE:
LICENSES ARE ADDRESS: ����� g� ��/(% CITY e rp � STATE 1YIAIZIP�,��
REQUIRED FOR GAS pHONE: l��3-%�� TSBCJ CELL:__,�[/!1 °t_ FAX: /�aQ��
AND HVAC
CITY GAS LICENSE # CITY HVAC LICENSE # EXP:
PERMIT TYPE I � MULTI-FAMILY �,COMMERC[AL ❑ INST[TUTIONAL ❑ CONDO ❑ INDUSTRIAL ❑ SWIMMING POOL
❑ OTHER
TYPE OF WORK: �� NEW �REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK:
I _ ��//l�w �i�/ /�/f l/A w .: � A�l
G
r.
EQUIPMENT INSTALLED MFG: j„f�� �d�,� �. / MODEL: �/� SIZEBTU
MFG: MODE[,: SIZEBTU
MFG: MODEL: SIZEBTU
A/C DUCT WORK ROOF TOP UN1T (RTU)
� BOILER FURNACE REFRIGERATION
CLASS 1 HOOD GAS APPLIANCE STEAM/HOT WATER HEATER
CLASS II HOOD GAS PIPING SWIMMING POOL
� COMMERCIAL KITCHEN POOL HEATER OTHER
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION: $_ 5 q�, DO
PERMIT FEE $ �� ��� 1.25% OF JOB VALUATION / MINIMUM FEE $35.00
SURCHARGE $_ VALUATION x .0005 / MINIMUM .50
TOTAL DUE $ 'j�(p ,' MINIMUM $35.50
THIS IS AN APPL[CATION FOR A PERMIT-NOT VALID UNTIL PROGESSED
1 hereby apply for a mechanical parmit 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�ridley 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 on site; that the work will be in accordance
with the approved plan in the case of all work which requires re iew an approval of plans.
SIGNATURE OF APPLICANT : ������i ����----n����PRIT NAME: //o'f/'/�' � DATE: ..3 I
APPROVAL INSPECTOR SIGNATURE:
City of Fridley
Building Inspections Department
6431 iJniversity Avenue NE, Fridley, MN 55432
7F'�_57�_�f(14 FAX• 7F'�_5(1�_4977
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