P - 42749Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � .�Z
SI1'E r�DDRESS _
TfIIS �PPLICANT IS:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTI\-E 2-19-09
� 0�1NER
PROPERTY N�
�wNER/ ADDRESS:
TENANT
PHONE: °
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
E-MtIII.
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CONTACT PERSON: ym0
STATE LICENSE # � � 7 R74_7� DATE
ADDRESS:
PHONE
F?.I�•IIL1" � Tu'O F.MIIL,1"
❑ NE�L' �REPLACEr-�NT
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FAX
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❑ TO WNHOUSE
Pernut No.
Receit-ed
;� _ � .
ST�TE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBII2 OF EACIi BELOV1�
Equipment Installed MFG: MODEL: SIZE/BTU
MFG: MODEL: / tJ SIZFJB � �
MFG: � MODEL: L � SIZFJBTU �
�C 525.00 PLACE (GAS) $15.00 GAS RANGFJOVEN 510.00
_AIK TO AIIt EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRII.L 510.00
BOII.ER 535.00 �FCJKNACE 535.00 GAS iJNIT HTR S 10.00
_Q�iNEY LINER 510.00 GAS DRYER $10.00 POOL HEATER 535.00
DUCT WORK S10.00 _GAS PIPING 510.00 VENTII.ATOR 515.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID IJNTTI. PROCESSED
I hereb}� appl_y for a building pemiit and I acl<no« ledge that the information above is complete and accurate; that the «�ork �vill be in
conformance �vith the ordinances and codes o �ty of Fridley and �t-ith the Miunesota Construction Codes; that I understand this is
not a erniit but onl • lic on for a it and •ork is not to start with t a erniit; that the wo tt�ill be in acco ance witl� the
approved plan in th } ase o al����� quires eview and approval of P�� P. . i � �
SIGNATURE OF
N_��
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 7b3-502-4977