P - 45740Building MECHANICAL Permit No.: `
Inspections RESIDENTIAL APPLICATION Received By:\�Y
763-572-3604 �ITY OF FRIDLEY D��' � �
763-502-4977 FAX EFFECTivE i-l-zoil �
DATE LQ- ��( I� YOUR E-MAIL ADDRESS I I� � Q � I�I
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY NaME: S
OWNER/ ADDRESS:� rn�, CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR COMPANY NAME:
SUBMIT A COPY OF CONTACT PERSON: TING Ee AI
YOUR STATE STATE LICENSE # `�� Z387 STATION PAR�A�,A1� � l0 3�O �-�O
LrcErrsE wrTx aDD�ss: D4YER, 55304 clfiY sTATE zir
APPLICATION
PHONE
PERMIT TYPE ja'�jD�GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
r
TYPE OF WORK: � NEW �EPLACEMENT ❑ ALTERATION/REMODEL
l—
DETAILED DESCRIPTION OF WORK 9C
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANU 2006 A5HRAE HANDBOOK L j'i'O /
Equipment Installed MFG: � PPIZl MODEL: (J CS � SIZEBTU C)
MFG: �,�Q MODEL��-nr� aay SIZEBTU �. ��
MFG: MODEL: SIZE/BTU
I 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
BOILER $35.00 LFURNACE $35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 `POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
Number of fi�ctures @ $10.00 ; x $lO.OQ = $
Number of fixiures @ $15.00 x $15.00 = $
�
Number of fi�ctures' @$25.00 � x$25.00 =$ c� S
Number of fixtures @ $35.00 l x $35.00 = $ � ��
State Surcharge = $ 5.00
MINIMUM FEE $40.00) Tota1= $ � �' �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 o 1 rk whic ires review and approval of plans.
SIGNATURE OF APPLIC � PRINT NAh�/ [[C�C�[(� �1 �/?2v DATE �/� �/�
APPROVAL INSPECTORS SIG ATURE DATE
PLEASE NOTE: SEPARATE PERMITS ARE RE UIRED FORBUILDING, ELECTRICAL AND MECHA1�lICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977