P - 45671Building
Inspections
763-572-3604
763-502-4977 FAX
DATE G � /�
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
SITE ADDRESS �� �1 Ccs -) t^���
THIS APPLICANT IS: ❑ OWNER
PROPERTY NAME: I ���
OWNER/
TENANT ADDRESS: "�`�'(vc
PHONE: ''Ife.� �
YOUR E-MAIL ADDRESS
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�CONTRACTOR
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PermitNo.: ,��
Received By:
Date Rec'
ATE
CONTRACTOR COMPANY NAME: � � lT'� v
SUBMIT A COPY OF CONTACT PERSON:
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: (p,��F � I„CQ���-�i/� �. CITY�Q7j�uG1 �`l Q�. STATEA�ZIP
APPLICATION pHONE`�(O�S�,�.,�'��, - [�(�(� FAX "7(�'°��--�,�f., — �<�lC�_
PERMIT TYPE
TYPE OF WORK:
�i"SINGLE FAMILY � TWO FAMILY
❑ NEW � REPLACEMENT
DETAILED DESCRIPTION OF WORK
0
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE AEAT LOSS CALC'S PER MANUA J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: N+rolC MODEL: ��FI� X D Zy SIZE/BT'U Zyi ��
MFG: MODEL: SIZEBN
MFG: MODEL: SIZE/BTU
�A/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
BOtLER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $]0.00 POOL HEATER $35.00
_DUCT WORK $10.00 _GAS PIPING $ ] 0.00 VENTILATOR $15.00
THTS 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 complete 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 application for a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all wo k which requires review and a proval of plans.
SIGNATURE OF APPLICANT � � �� RINT�CME /�`il �*�°' J��fj S �ATE � Z � �
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SIGNA
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� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977