P - 42170Building MECHANICAL Permit No.:
Inspections RESIDENTIAL APPLICATIOl�I Received By:► � l�
763-572-3604 CITY OF FRIDLEY Da��'`��� d� 2a
763-502-4977 FAX EFFECTivE �-i-zo�o
DATE �� �` I�� 1 YOUR E-MAIL ADDRESS
SITE ADDRESS � �i � � - S ��� �"�rGf'L�-�
THIS APPLICANT IS: ❑ OWNER NTRACTOR
PROPERTY NaivtE: h m ( c.�t
OWNER/ ADDRESS: � J� f � SZ� �� CITY �irtGil��1 STAT�'`ZIP�.3 �
TENANT pHONE: `�'] c�S �v �- � � Z(o �-
CONTRACTOR COMPANY NAME: � o��
SUBMIT A COPY OF CONTACT PERSON: L--� e:�i'v1 r�—
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH pDDRESS: a J�� S (3Y� ���� _%J�ITY � Ut°Y STA'1'L� "'�ZIPS S 3D N
APPLICATION pHONE � (D�—��' `[ vOO FAX
PERMIT TYPE INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK' � NEW �PLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK (�/
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE H�AT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZEBTU
MFG: ��n� m MODEL: �G TD � SIZEBTU ��� 6 OD
MFG: MODEL: SIZEBN
A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 IREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00 �
_BOILER $35.00 �URNACE $35.00 GAS iJNIT HTR $10.00
CHIMNEY LINER $10.00 � GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
iVttirib6rO� �Xtui"e3 (i� �Ifl;iif} ; X $IU.{?U s' $ � , � �'; � `'� � ,,Y� ���f �,,� �:�c,� �
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Number of fixtures @ $15.00 ' x $15.00 = $
Number of fixtures @ $25:00 x $25;00 = $
Number of fixtures @$35.00 1 x$35.00 =$ � S'vU
State Surcharge = $� ,�' � �
MINIMUM FEE $35.50) Tota1= $ � �
THIS IS AN APPLICATION 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 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 appli ation fo zl 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 al work ich re ires review and approval of plans.
SIGNATURE �F APPLICANT PRINT NAME �e P�� "� �' -DA�TE ,�'� '- !�
APPROVAL INSPECTORS SIGIyA DATE
i PLEASE NOTE: SE ERMITS ARE RE�, LTIRED FC3R BtJIiI7iP�t�a �.�C�Ti":I�� ,p►I�1�' i�:' .. �.`.. =`�
%` City of Fridley
Rnilrlina Tner�prtinnc ilPnArtment
a ----i r---- -� --
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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