P - 62700Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
DATE "( ��" I Z YOUR E-MAIL ADDRESS
SITEADDRESS�j� � �6K.�� O�{..� ��vr l..l f't�'=-�b�w
THIS APPLICANT IS: ❑ OWNER �'CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
ADDRESS: �S.fs /v. bbc.�.��. �R-' CITY.
PHONE: (pIa' ag`Z� Qsq�
COMPANY NAME: (�� u�✓
CONTACT PERSON: C�k� ��
Permit No.: ,.;,1 �
Received B�:
TE K a ZIP SS W3
STATE LICENSE # EXP DATE _
ADDRESS: Ro�-�% O Ma.�,v� � *%� CITY , Il.ltl �� L STATE:7� ZIP SSY�3'Z'
PHONE �I �� �I S�F a� 9 q FAX
�SINGLE FAMILY ❑ TWO FAMILY
❑ NEW �PLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �S{:a ZI r�t�Ol t�.0 r, ...� ��.�A,�. � �' ��'Z
�..�4 r'+ � � �`'. �-✓
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE IiEAT LOSS CALC'S PER MANUA J 2J,r 006�ASHRAE HANDBOOK. � Q
Equipment Installed MFG: rC�t v MODEL: � G P� b� �A�1 �IC� SIZEBTU ��
MFG: � V� V' 10 MODEL: lI4N L. d al..��J�d L SIZEBTU o1 Tu h
% MFG: MODEL: SIZEBTU
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 $]0.00
BOILER $35.00 �C FURNACE $35.00 GAS UNIT HTR $] 0.00
CHIMNEY LINER $] 0.00 GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $]0.00 _GAS PIPING $10.00 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 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 f r ermit and ork is not to start without a permit; that the work will be in accordance with the
approved plan in the case of ali work which quire r iew and approval of plans.
SIGNATURE OF APPLICANT � �tiw P�INT NAME � i'► �� S ��'� � �bATE � � 4 � � Y-
�
APPROVAL INSPECTORS
-' City of Fridley
ilding Inspections Department :
1 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977