P - 35278Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-t-20] ]
Permit No.:'�.{i � i�5
Received By:�_
Date ��� ���
DATE ZZ �v L� Z� �� YOUR E-MAIL ADDRESS iN Z'TI "" �4�9 e�.SbN A� 4G►'hGZ►,� NC,,,
SITEADDRESS IZ.Z.'� �.�ls T�Q.�'LtT /'JG �FR���Y
►'HIS APPLICANT IS: �'[QWNER ❑CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICA�'TON
PERMIT TYPE
ADDRESS: �Z'7..3 Q���S 1�.C�,�►��' CITY �'�1�(.�1' STATEM1�i Z[P�+S4��
PHONE: LIZ, "iO�L1 ��7g�'Sr
COMPANY NAME:
CONTACT PERSON:
STATE LICENSE #
EXP DATE
ADDRESS: CITY
PHONE FAX
�SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: I� NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK
�QLTERATION/REMODEL
�N
TATE ZIP,
FEES ARE BASED ON SI0.00 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 MFG: NvTOfJ C MODEL: SIZE/BTU �a G'f �
$ � '�+N
MFG:
A/C $25.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $ ] 0.00
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10:00
THIS IS
I hereby apply for a building permit an
conformance with the ordinances and o�
not a permit but only an applicati n <
approved plan in the case of all �r j
SIGNATURE OF APPLICANT
APPROVALINSPECTORSSIGNATURE
SIZEJBTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
V ENTI LATOR $15.00
TION FOR A PERMIT-NOT VALID UNTIL PROCESSED
wledge that the information above is complete and accurate; that the work will be in
e City of Fridley and with the Minnesota Construction Codes; that I understand this is
and work is not to start without a permit; that the work will be in accordance with the
res review and approval of plans.
NAME M1}��'�� �5��`� DATE ZZ�.� V�-Y Z� (,�
DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977