P - 36781Building
Inspections
763-572-3604
763-502-4977/�'AX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE Z-19-09
DATE �1�-1 ���
SITE �DRESS �� �''y �
THIS �PPLICANT IS= O O�l'NER
PROPERTY N.,�,�:
OWNER/ aDDRESS: ,� C
TENANT /'
PHONE: VlI �-
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
E-MAII,
CO�IPANl N.�fE. ��a� ��ai ���ca�a �y an r-.n v..� �..�.�.......y
CONT�CT PERSON: Ym0
---ft�nrrea�alis; AAM-5�4�-344�
STATE LICENSE # R 17_R'�d_7� DATE
?�DDRESS:
PHONE
❑ NE�V
CITY
FAX
F�IILl' ❑ TLi?O F.��III,1' ❑ TOWNHOUSE
�EPLACEI�•fENT ❑ ALTERATION'REhiUDEL
DETAILED DESCRIPTION OF WURK
Pennit No.
Received Bv:
�e 12���:
ATE ZIP
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBII2 OF EACH BELO�
fiquipmentlnstalled MEG: MODEL: SIZFJBTU
MFG: �� MODEL: � SIZFIBTU � "' '�
MFG: MODEL: SFZFBTU
�C 525.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN 510.00
_AIR TO AIlt EXCHANGEER $15 _FIREPLACE (WOOD) 535.00 NEW GAS GRILL 510.00
BOII.ER 535.00 _FURNACE 535.00 GAS UNCl' HTR 510.00
QID�IIdEY LINER 510.00 _GAS DRYER $10.00 POOL EiEATER �i5.00
DUCT WORK $10.00 _ _GAS PIPING $10.00 VENIILATOR 515.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNITI. PROCESSED
I hereb_y apply for a building perniit and a��.ledge ttiat the information above is complete and accurate; that the «�ork wili be in
conformance �vith the � ances and c the Cin� of Fridley and ���ith the Minnesota Construction Codes; that I understand this is
not a perniit but onl an ap li• ti for pe iit and work is not to start «�ith t a perniit; tt�at the �vo � t3-ill be in acco ance tvith the
approved plan in e case o o �ch quires review and approval of p .
SIGNATCIRE UF �P C: pRII•1T N�hfE �
/ '
City of Fridle�
Building Inspectioas Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977