P - 42189Building
Inspections
763-572-3604
'763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2010
DATE U I( YOUR E-MAIL ADDRESS
SITE ADDRESS J"1 ��U '�` �J , Y el°i�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
NAME: r�.{�-[ (_t
ADDRESS: J�,�""' ����� �-.
PHONE: �� ��- -- ! - t (J �`
COMPANY NAME: ' , f-
CONTACT PERSON: �Q � ylt.�
Permit No.:
Received By
STATE�ZIP�',
STATE LICENSE # EXP DATE
ADDRESS:s�,� Yf� (51'1 �`'l Jl.��.L� CITY �'}�' ['� ltE� l STAT��IP
PHONE ?j'"'] "ZlC3UQ • FAX
TYPE OF WORK: I� NEW
FAMILY ❑ TWO FAMILY
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
I� � � � � ..
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUA 2006 ASHRAE HANDBOOK. /+ n
Equipment Installed MFG: -�� Y'�� MODEL: C.� ( �� SIZE/BTU � ��% C>
*��_ �
._._:-...;
�. A/C $25.0�
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
1 FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $]0.00
SIZE/BTU
SIZE/BTU
GAS RANGE/OVEN $]0.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $I5.00
.� � r, �. �,. r '.-i"`".`_§ 4s+ . �.. ��. $�q � �.y`�'�� .Y:,�,�*3f?ti i z�'�"' a .,''���'s"�,�� '.� �.Y a� � ,F' a "i'4 ,. ' M1
1�Q��^ '� i�
�'�.flV � �6 �•i ��, a� �` � �
Number af fixtur�s;t�,���.�lQ � � � < ,: ��
, ��
State Surcharge = � ,� �� �
,
,ti � � � ��� �
�.
(MINIMUM FEE ��5.50} T�ta1= � � `� ` ��
THIS IS AN APPL[CATION 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 applicatio for a rrru��t nd work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all wd�c��l�'e9sr'�es review and approval of plans. ,r� ]
S[GNATURE OF APPLICANT
APPROVALINSPECTORS
DATE '.i
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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