P - 42744/�'�vi�
Building MECHANICAL Per�it No.: a 6 � a�
Inspections RESIDENTIAL APPLICATION Received B:
763-572-3604 CITY OF FRIDLEY vat
763-502-4977 FAX ���: �� � � � � � 1 �
EFFECTIVE 1-1-08
DATE / I I I � YOUR E-MAIL ADDRESS
SITE ADDRESS ( 1 5
THIS APPLICANT IS: ❑ OWNER EfCONTRA OR
PROPERTY NAME: �g � � �j�j c�'/'�
OWNER/ ADDRESS: J�_ �— � C,C�t� CITY �vs
TENANT 1 '� �` T� L� I tr°Ci STATE�LIP
PHONE: '�10?�"' �� "` O l C� �
CONTRACTOR COMPANY NAME: QYSI�'1 "�Cl_�-�(J�,G�� ( (��`y�t.��LlyC
NOTE:
SEPARATE CITY CONTACT PERSON: Kc 1( (,,__ /Y'l�,��-,
LICENSES ARE STATE LICENSE # L %"� EXP DATE _�C, �(y /�
REQUIRED FOR GAS / � �t
AND HVAC. ADDRESS: �G+.���i G.G Q/Za/ �f(M /��CITY �/�07J /G,IG/] �1'�.STATEIrI�CIP
SUBMIT COPY OF BOND pHONE 7� 3" �J' ��p '"CiCq�o� FAX _]���" �j3 d�.'2l
AND INSURANCE ����—
PERMIT TYPE ��GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: � NEw Lr7'REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK { ,.e, � j�
✓lr° l.�.) L.�v���,1 �p-�,'�r-�-��f
PER MS 16B.665 the permit fee is a minimum of $15.00 or 5% of the total cost up to $500.00, whichever is greater, for the
improvement, installation or replacement of a residential fixture, excluding the fixtures. (This should reflect only the cost of labor )
OR
Labor cost under $300 =$15.00. Labor cost between $3d0 to $500 = cost of labor x.OS =
FOR PROJECTS WHERE LABOR EXCEEDS $500, FEES ARE BASED QN 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL
NUMBER OF EACH BELOVI�
EquipmentInstalled MFG: �..GY�r1J��': MODEL:rg � SIZE/BN�_
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WQOD) $35.00 _NEW GAS GRII.L $10.00
BOILER $35.00 �/FURNACE $35.00 GAS LJNIT HTR $]0.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POQL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
PERMIT FEE PROJECTS F(�R IIND`ER``$5'DO .` , �FaR1�1IT FEE FQR PR07ECT5. aVER $500:`
Permit Fee $ Number of fixtures @$10.00 x$10.00 =$
Surcharge $ .50 Number of fixtures @ $15.00 x $15.00 = $
TOTAL DUE $ OR Number of fixtures @$25.00 x$25.00 =$
Number of fixtures @$35.00 1 x$35.00 =$
State Surcharge = $ .50
MINIMUM $ %J�- MINIMUM $15.50 Tota1= $ , �i
_�
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 Fridiey 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; that the work will be in accor a e with t4e approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT � PRINT NAME /VG!`� ��� DATE
APPROVED BY DATE
PI�E��3�iC3'� � ��F��'E��'�f�i: . �. ., ���I��-C}S�.�B�IL� j�"° A�.':�I+�I}'�C���AI,:�ORK :
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977