P - 45826Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
DATE �" �'' �� YOUR E-MA[L ADDRESS
SITEADDRESS "��j�� �Sr 47�v C,,,.�C;.!'� �..��
THIS APPLICANT IS: � ❑ OWNER $�ONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
Permit No.:
Received By:
Dat��d:`�
NAME: �� L c_ J 1 f� r+�'L� `S�"
ADDRESS: S S LC; �c�S 1 �Q a)�"n f�i� ��it��' � � J ���r STATE��ZIP SSy 3z
PHONE: '1 S Z' �U 7"%� S?j_
COMPANY NAME:
CONTACT PERSON:
�
sTaTE L�cErrsE a 1815 E��t 41�� St��,r�l�@�,
ADDRESS: M�(ii�$�IIS. ESAPII rlrltii�%�i��� STATE ZIP
PHONE ��i''i �ii ��,1,T�
� SINGLE FAMILY ❑ TWO FAMILY
❑ NEW I� REPLACEMENT
❑ TOWNHOUSE
❑ ALTERAT[ON/REMODEL
DETAILED DESCRIPTION OF WORK ��7 � � �_. � � � � �-�-��� ��_��__, � �> �
� _ [� 1 '�'I ` � S c �t
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: SiZEBTU
�,/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $]0.00 VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building ermit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordina es and cod of t C' of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an app ` atio for p t n� wvork is not to start without a permit; that the work will be in accordance with the
approved plan in the case of w� ich r e� re, iew and approval of plans. j
SIGNATURE OF APPLICANT
APPROVALINSPECTORS
TURE
RINT NA
DATE
�� ;' City of Fridley
/�
Biiilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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