P - 44341Building
Ins�ections
'��3-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
E�FECTIVE 7-1-2010
DATE '�I • I i- � � YOUR E-MAIL ADDRESS
sITE aDDxESS � S s rf hl 41�.i..e,1� � C� �— F�. ��i� :i ��f3 S-
THIS APPLICANT TS: ❑ OWNER �CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
Permit No :,�(��- ��j
Received B : v� �
R�(`'� �Tt�� 01Q
Date R�l't3.
NAME: h'�4-C �1 G t� (Z! � n
ADDRESS: � 5 S� �I QI�� „t_I i-, �l a_" CITY F� �Aj� STATE�''� ZIPSSI3Z
PHONE: 'Z i3- -]� -7 � �f 3 L �
COMPANY NAME:
CONTACTPERSON:
�I
STATE LICENSE # EXP DATE
ADDRESS: gel,.�i O d-'(p., t,�.
cSle O..�L' CITY F_ STATE��"ZIP SS�3i
PHONE FAX
Qf SINGLE FAMILY ❑ TWO FAMILY
a t�rEw �ItEPLACEMENT
DETAILED DESCRII'TION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
� tt��n � C��- �ls-r� n A �� -►
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed �ia. MFG: �►�t MODEL: 3tSA� r/�s' bb7a SIZEBTU ? � � G� v
��' MFG: A.��' MODEL: I���'�� �� i
MFG: MODEL:
I A/C 525.00 FIREPLACE (GAS) $15.00
AIIt TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00
BOILER $35.00 1 FURNACE $35.00
_CHIMNEY LINER $10.00 _GAS DRYER $10.00
DUCT WORK $10.00 GAS PIPING $10.00
SIZE/BTU �'ra � o"`�
SIZE/BTU
_GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNTf HTR $ ] 0.00
POOL HBATER $35.00
VENTILATOR $15.00
THIS I�b'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 work which requires review and approval of plans.
SIGNATURE OF APPLICANT
APPROVAL INSPECTORS SIGNA
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
DATE �I - e�0 .. t �