P - 36721Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDEli1TIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
DATE ��' S•/� YOUR E-MAIL ADDRESS
SITE ADDRESS S p O �S �2 !� e,pp �j'�
THIS APPLICANT IS: ❑ OWIVER ❑CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
NAME: �' c� � 1�, '1�' c^ 1 1�M O� !ij
ADDRESS: G L� ,o ✓' 2. CITY
PHONE: —J (o ?j . --7 � O . � ( p �{ 50
COMPANY NAME:
CONTACT PERSON: Home Energy Center
- 2415 Annapolis Lane N #170
STATE LICENSE #_ Plymouth MN 55441
ADDRESS: 763-476-1990 fax 763-476-1143
_ _
PHONE
❑ NEW
FAMILY ❑ TWO FAMILY
�PLACEMENT
DETAILED DESCRIPTION OF WORK
FAX
� TOWNHOUSE
❑ ALTERATION/REMODEL
,
Permit No.:
Received By:
��"�e�� 7
ATE ZIP.
ATE ZIP_
FEES ARE BASED ON $10.00 PER FIXTURE, E EPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU J 006 ASHRAE HANDBOOK.
Fquipment Installed MODEL: ���- � SIZElBTU �� `flp �
MFG:
MODEL:
�% MFG: MODEL:
✓A/C $25.00 FIREPLACE (GAS) $15.00
_AIR TO A[R EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER 535.00 FURNACE E35.00
CHIMNEY L1NER �10.00 GAS DRYER 510.00
_DUCT WORK 510.00 GAS PIPING $10:00
SIZEB'tU
SIZFJBTU
GAS RANGE/OVEN 510.00
NEW GAS GR1LL $10.00
GAS UN[T HTR $10.00
POOL HEATER 535.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is compiete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an applicatio for a permit and work is not to start without a permit; that the work wilt be in accordance with the
approved plan in the cas� of al) �r c which �quires review and approval of pla,�s. ,
SIGNATURE QF
SIGNA
DATE
�--�j City of Fridley
B�lding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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