P - 46726Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE �q� � U y ��� YOUR E-MAIL ADDRESS
SiTE ADDRESS � 3�� � � C �i2- / a C. E"5 M
THIS APPLICANT IS: �WNER ❑CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
Permit No.:
Received By:
NAME: S'�' L° U�--rL `�/�f' lC L�
ADDRESS: ,.fi3i/ �� S�` �� CITY �%�I �%LEJ` STATBN�''ZIPS�TL
PHONE: � G 3'" $ i/— i�3
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #
EXPDATE
ADDRESS: CITY
PHONE FAX
FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I�W � REPLACEMENT ❑ ALTERATfON/REMODEL
DETAILED DESCi�PTIQN OF WORK %I-a�� ��"�Pii2� /Dk ,�-� T�t
i9-� e
STATE ZIP,
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU� J 2006 ASHRAE HANDBOOK.
Equipmentlnstalled MFG: �"`P� �Z� MODEL:PI%21 U SIZE/BT'U j0 �L
A/C $25.00
_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
_FURNACE $35.00
GAS DRYER $10.00
, _GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
�GAS UNIT HTR E10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit a wledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances co s of the 'ty of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applic i fo permit ork is not to start without a permit; that the work will be in accordance with the
approved plan in the c e of which re e view and approval of plans
--� %�}�% 7a/
SIGNATURE OF AP LIC PRiNT NAMEs��� � J�� G� DATE f� /� �/ � w`
TURE
L
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, IvIN 55432
763-572-3604 FAX: 763-502-4977
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