P - 42761Building MECHANICAL Pe�itrto.:2��U�o�l �
Inspections RESIDENTIAL APPLICATION Re �g � `�
763-572-3604 � �� U ��i� �Q
763-502-4977 FAX �ZTY OF Fi�D�E�[ Date Rec'd:
FF£�CTtVE 1-]-QR
DA'1'L
SI7'E ADC)121SS _� �_�Q{,
TI3IS APPLICANT IS: ❑
PROPER'I'Y
OWNER/
TENANT
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YOUi2 E-MAIL !�DDRESS
CONTRACTOR
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�U`�G��' IV�-
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CONTRACTOR cOhtl �NY Na�:
NOTE:
SEP 1RATG C7TY CON 'ACT PERSON:
LICENSES ARE STAT � I,ICENSE #
I2EQLnKED FQR GAS
nrm xvnc. Avix Iss: r G o
SUBMIT CdPY OF BdND �-10� F�_�Q�'L
AND INSURANCF.
PERMIT TYPE �,si � Gt.E FAn�u�,�'
TYPE OF WORK: � �' �
�- �
ci� ,�� �= s�•�xE tr�zly SS 2
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❑ TWO FAIv1II,Y ❑ TOWNIIOUSE
"EMI:NT ❑ AL'IF..RATiONlREMODfiL
TE�ZIPS���1
DF,TAILED DESCRIPTION )I' WOI2K
PER M5 1fiB.665 the permit �e is a minimum of $15.00 or 5%of the totnl cost up to $5@t1.00, whichever is greater, for the
improvement, installation or r�placement of a residential fixture, excluding the fistures. (This should reflect only the cost of labor )
OR
Labor wsi uncier $300 =$I5. �. Labor cost between $300 to $500 = cost of labor x.OS =
FQR PROJECTS WIiERE I.A13QR
N[JMBER aF EACH BELOVI�
Equipment Installed
A/C $25.00
AIR TO AIR EIGHANGEER $1
BOILER 535.00
CIIIMNEY LINER $10.00
DUC'T WORK SI(1.00
PERMIT FEE PROJECTS FC
Permit Fee
Surcharge
TOTAL DITE
�EEDS SSpp, FEES ARE BASED ON 510.00 P'ER FIA'1'[JRE, EYCEPI' WIIERE NOTED. FIX7'I7RES: (INDiCATE TOTAL
IbiFG: IUM�p YtrvuQl�( AiODEL: C� WI P�l �.Qrl ZL sizEr$ni `I S
MFG: MODEL: SIZE/BT[J
l�'G: MODEL: SiZEfBTU --__
__..___._ _ _
_FII2EPI..ACE (GAS) SI5.00 GAS RANGT:lOVEN 810.0(1
FIREPLACE (WOOD) Si5.00 NEW GAS GRILL 510.00
�FURNACE ��.W GAS LJNIT HTR 510.00
GAS DRYER $10.00 POOL HEATII2 �5.(Xi
GAS PIPING S10.Q0 VENTILATOR 515.00
UNDER $500 PERMIT FEE FOR PROJECTS OVER $500
� Number of fixtures (?a, $10.00 x $10.Q0 = $
$ .50 Number of fiaetures (a� $15.00 x $15.00 = $
$ OR Number of fixtw�e,�s (� 525.00 x S25.Q0 = S
Number of iixtures @ $35.00 � x $35.00 = $�—
S2ate Si:rct�g� _ $ �', ��
NIMUM $15.50 11�ID+IIMUM $15.50 Tota1= $��
THIS IS AN A�LICATION FOR A PERM[T-NOT V A1,ID IJN77L PROCF.SSED
I heneby apply fa� a mechanical pe.�m t and I acknowledge ffiat the informatioan above is c�mpkte and aocurate; that 16e woiic wid be ie co�'ormaoc� wilh the ord�artc�s
and codex of tlae City of Fridley and �ith the Minnesala Coastruction Codes; thai I understand this is rwt a permit but only an application for a pe�mit and work is not !o
starl withottt a pe�mit; that the work � ill be in accordance wiffi tl�e approved p}m ' the case of all work which reyuires rcview and approvai of plms.
SIGNATI7ItE OF APPLIC T��� � PRINT NAME�� � I A ��� �
���. n�� � .
APPROVED BY DATE
PL]3ASE NOTE: SEPAF�ATE PERNIITS ARE
City of Fridley
Building Inapections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3fi(}4 PAX: 763-5021l97?