P - 40838Building MECHANICAL Permit rlo.: 8 Z�
Inspections COMMERCIAL APPLICATION Received By:
�63-s�2-3604 CITY OF FRIDLEY ��� �� 2 ����
763-502-4977 FAX EFFECT[VE 1-I-2011
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS � � �_^� �/�, A � �� � L ��'"'
THIS APPLICANT IS: ❑ OWNER OCONTRACTOR ❑ARCHITECT/ENGINEER
PROPERTY NAME:
OWNER/ pDDRESS: CITY STATE Z[P
TENANT
PHONE: CELL: FAX:
CONTRACTOR COMPANY NAME: � �, � ,� y�� (o "�,�
NOTE: CONTACT PERSON: � O � � �
SEPARATE CITY STATE BOND # EXP DATE:
LICENSES ARE ADDRESS:� ���� �� J�-� C CITY �"(> C- . � t. �� STATF�I�21P
REQUIRED FOR GAS pHONE: �( Z'�- �(-��� CELL: �1 n FAX:
AND HVAC �
CITY GAS LICENSE # CITY HVAC LICENSE # EXP:
PERMIT TYPE ULTI-FAMILY ❑ COMMERCIAL ❑ INSTITUTIONAL O CONDO ❑ INDUSTRIAL ❑ SWIMMING POOL
❑ OTHER
TYPE OF WORK: � NEW �PLACEMENT � ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK:
� �_ -t"' � ,S� �� �%� �
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EQUIPMENT INSTALLED MFG: MODEL: SIZEBTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: S1ZE/BTU
_ A/C DUCT WORK ROOF TOP UNIT (RTU)
BOILER FURNACE REFRIGERATION
CLASS 1 HOOD GAS APPLIANCE STEAM/HOT WATER HEATER
CLA5S II HOOD GAS PIPING SWIMMING POOL
COMMERCIAL KITCHEN POOL HEATER OTHER
ALL FEES ARE BASED ON VALUATION, INCLUD�'u THE COST OF LABOR AND MATERIALS:
TOTAL 30B VALUATION: $;�-., Z�d — �-�
PERMIT FEE $_. <?� 1.25% OF JOB VALUATION / MINIMUM FEE $35.00
SURCHARGE $ � , VALUATION x .0005 / MINIMUM .50
TOTAL DUE $ MINIMUM $35.50
THIS IS AlV 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicati per ' d work is not start without a permit on site; that the work will be in accordance
with the approved plan in c se of o ich requires r' and approval of plans.
o �" , G � �
SIGNATURE OF APPLICANT : PRINT v1E: `
APPROVAL INSPECTOR SIGNATURE: /'
` DATF� �r
` � ' . � ��. �� ' w '
� Citv of Fridlev
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
7�'�_i7�_'�((1Q FAX• 7F't_5(1�-4977