P - 35065Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
�RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
DATE � Z`1 O— l U YOUR E-MAIL ADDRESS
SITEADDRESS ') `,� �� .,,l�r`{ � V r P7T' N.-�C.
THIS APPLICANT IS: C7 OWNER Glfe6NTRACTOR
PROPERTY tvaME: "�o ,�,� �,J �. ,,� c�.�S �
OWNER/ ADDRESS: � "� � �+ S i� �
TENANT T `��� r
PHONE: � Ej 3"2 Z 1`�'►�'�
Permit No.:
Received
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STATE h i1ZIP S� �'I�3 �
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON: RESIDENTia� �{€���,� _�
YOUR STATE STATE LICENSE # 1815 East 4 i Q� i��{ ���TE
LICENSE WITH ADDRESS: mneapolis, i�*atv �5q.p7.3q�5 CITY STATE ZIP
APPLICATION pHONE P,,, 1 Z— ^T Z�(—1
��iC� FAX
PERMIT TYPE
TYPE OF WORK:
�INGLE FAMILY ❑ TWO FAMILY
❑ NEW �EPLACEMENT
DETAILED DESCRIPTION OF WORK
�_�� ��� �-�.. 2
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
�Tn a, re /`�. c-r�c r
�. � � c�
.�.. ._ �
FEES ARE BASED ON $10.00 PER FIX,TURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
EquipmentInstalled MFG: Gt��f tt�"� MODEL: s,�M�L(� �Q SIZE/BTU ��[���'
MFG: L a f�'� a.� MODEL: Zt'(P1-(�'SZ-� SIZEBTU Z�_ O� �'
�'o A/C $25.00
'O
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
I hereby apply for a building per
conformance with the ordinances
not a permit but only an applicati
approved plan in the case of all w
SIGNATURE OF APPLICANT
APPROVAL INSPECTORS SIGNA
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
� �FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZEBTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
_GAS LJNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
and I acknowled e that the information above is complete and accurate; that the work will be in
codes of e of Fridley and with the Minnesota Construction Codes; that I understand this is
or a p t a ork is not to start without a permit; that the work will be in accordance with the
� quir s evAew and �proval of plans.
C- r� ��ATE f Z► t Q '�U
[Z1
� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977