P - 35750Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201 I
DATE Z �
SITE ADDRESS / �(+
THIS APPLICANT IS: ❑
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOURSTATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
L+�CONTRACTOR
rk / .�,.�
NAME: �I �I.T % �r'��' N
ADDRESS:� ��'v Pr'S /.� ��i P wet� CiTY
PHONE: FJ 7 / �T iS� /� %�.�
COMPANY NAME:
CONTACT PERSON:
�
Permit No.:`�� .0�
Received By:
Date Rec'd� �- 11
ATE�Z[P.
STATE UCENSE #,��i'� 9i /�� EXP DATE ff�6�� Z
ADDRESS: �/fdY /i/ �7 CI'fY�s STATE/�A/ZIP��,L
PHONE __�I Z � �7 I ��� FAX
�.SINGLE FAMILY � TWO FAMILY
❑ NEW 0 REPLACEMENT
❑ TOWNHOUSE
�i4LTERAT10iJ/RENSODEL
DETAILED DESCRIPTION OF WORK 2� %F 7'lt �'a n S ,�� ��► I�i N r
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 MFG: MODEL: _ _ S1ZE/BTU
_A/C $25.00
_AIR TO AIR EXCHANGEER $15
BOILER $35.00
CIitMNEY LINER $10.00
/DUCT WORK $]0.00
MFG:
MODEL:
MFG: MODEL:
FIREPLACE (GAS) $I5.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
POOL HEATER $35.00
V ENTILATOR $ l 5.00
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 for a permit and work is not t 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 a roval of plans.
SIGNATURE OF APPLICANT 4 RINT T�ME ��'/J� /�a ✓�S�/��1 DATE L/�
APPROVAL INSPECTORS SIGNATURE
7 /2 � / / 1
L City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977