P - 42829Building MECHANICAL Permit No.:�.�1('�
Inspections COMMERCIAL APPLICATION Received By:y���
763-572-3604 CITY OF FRIDLEY ' � ? ����
763-502-4977 FAX EFFECTIVE I-1-2011 �F��
DATE C tl"� l'�d �� YOUR E-MAIL ADDRESS
SITE ADDRESS ��I �� � sj fi S f N�
THIS APPLfCANT IS: ❑ OWN�R �CONTRACTOR ❑ARCHITECT/ENGINEER
PROPERTY NAtvtE: � �"¢' iV �°i4a�'t/��f �'�s'
OWNER/ qDDRESS: I��/a.S �-�jC;' � 6� ti i� CITY S� /��t;,. C STATE•'�tiZ[P SS' `///
TEI�IANT
PHONE: �-5 �` �i Z�j ` Cn iC� � CELL: FAX:
CONTRACTOR COMPANY NAME: f �i�° C'�cQ � G� B!'L �`'
NOTE: CONTACT PERSON: �''� �� 7� I��r l'1S C
SEPAR.ATE CITY
STATE BOND # �-cS -`1$ 3�S '�t p EXP DATE: jJ- j S" V�
LICENSES ARE ADDRESS: � T E�S �-s:� �y �+� N�Y C(TY '� M S�Y STATE�+�t ^� ZIP ,SSS��'
REQUIRED FOR GAS pHONE: %�i �%�� �/�-
AND HVAC E �f����LL: FAX:
CITY GAS LICENSE # CITY HVAC LICENSE # EXP:
PERMIT TYPE � MULTI-FAMILY ❑ COMMERCIAL ❑ INSTITUTIONAL ❑ CONDO ❑ INDUSTRIAL ❑ SWIMMING POOL
q OTHER
TYPE OF WORK: � NEw �.REPLACEMENT ❑ ALTERATION/REMODEL
i
DETAILED DESCRIPTION OF WORK:
��CE � G, � l'3 G'c�.ti ¢ N�f- f�o ��'G. �e ff (.c. ,' f�t ti��v � lr�.•� 7'
S.A r'h r S: Z� �
EQUIPMENT INSTALLED MFG: MODEL: SIZEBTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SIZE/BTU
_�C Di1CT WORiC ROOF TOP UTJIT (RTU)
BOILER � FURNACE REFRIGERATION
CLASS 1 HOOD GAS APPL(ANCE 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: $ 3C�0. �
PERMIT FEE $ 3"�I �� 1.25% OF JOB VALUATION / MINIMUM FEE $35.00
SURCHARGE $ VALUATION x .0005 / MINtMUM .50
TOTAL DUE $ � MINIMUM $35.50
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a mechanical 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 on site; that the work will be in accordance
with the approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT :��''""'� l PRINT NAME: ..�- ({(� /r/?� C>S C dj DATE: jo - I% 20 �/
APPROVAL INSPECTOR SIGNATURE: DATE:
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
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