P - 42833Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
❑ OWNER
CONTRACTOR I COMPANY
CITY
Permit No'
Received By: % " "``-1,,
-- �;--
Date 17��1 � � � � �
SUBMIT A COPY OF CONTACT PERSON_ -
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: I%,"�j���{�.� •�• CITY 5
APPLICATION pHONE 1�IJ?j�7�'�C]�� FAX ���"��ZI' � Z
PERMIT TYPE y(°�GLE FAMILY ❑ TWO FAMILY
,�
TYPE OF WORK: ❑ �w �rLncE�rrr
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WAERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOR�
PROVIDE AEAT LOSS CALC'S PER MANU 06 A�HRAE RANDBOO �ODEL: PC�aM I�) ��IQ(J W U SIZEBTU l.{�V �U ��
Equipment Installed MFG: ,J(J
MFG: MODEL: SIZEBTU
MFG: MObEL: SIZEBTU
A/C $25.00 F7REPLACE (GA5) $15.00 _GAS RANGElOVEN 510.00
_AIR TO AIR EXCHANGEER SIS FIREPLACE (WOOD) $35.00 _NEW GAS GRILL EI0.00
_BOILER $35.00 �FURNACE $35.00 _GAS iJNIT HTR 510.00
_CHIlVINEY LINER $10_00 _GAS DRYER $10.00 _POOL I3EATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR 515.00
� ........... ..� ........,,v �,, w�....,., ,...-.,_.,.� ,,.
Number of fvctutes �,la $15.a0 x $i�.U� = $
Number af fixtures �a $25.00 x �25.OU = $
Number of fi�ctures @ $35.00 � x �35,00 = $ J �
State Surchazge = $ 5.00
(MIl�iIMUM �EE �4Q.001 Total = $ '�U ��
THIS IS AN APPLdCATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acla�►owledge 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 wjth the Mittnesota Construction Codes; that I understand tlus 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 worlc which requires review and app val of plans.
SIGNATURE OF APPLICANT ����J �I�� NAl� �"i j�L'� P v B��'ATE �� "O V
DATE
` City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
/