P - 46809Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATI�N
CITY OF FRIDLEY
DATE_ I�(� ( � YOUR E-MAIL ADDRESS
SITE ADDRESS � s k � • C•
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICEN5E WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
Permit No.:
Received By: i I tt��ff �
���� � � �
NAME: C4ro� '�'����
nnn�ss: 13g� Sk��r•�od� L n N� ci� �: ��o-� sT.aTF�N zir ss' /� r
PHONE•� •3 571- �gd Z �� o � �nnri_ ...�:.Jf��«cJ'., TNC',
�v� �r. �'--
co�� N.�[E: �+ha--F?RESID� HFARTH i� nt�m�
CONTACT PERSON: LIC. BC0512060
sTA� LrcErrsE # Exr va� 2700 FAIRVIEW AV 5113
CITY R � �'ATE ZIP
ADDRESS: 'w•' �c
7 t .v.�.a. �.�+� �
PHONE
FAMILY ❑ TWO FAMILY
��W ❑ REPLACEMENT
FAX
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �n c�_L+a s : K-.p (�" `� � l'�` s��^ C —
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDB��K. SIZEBTU ��
Equipment I�talled MFG: U�,�y�n L( o MODEL: % d
MFG:
MODEL:
�G: MODEL:
_A/C $25.00 �FIREPLACE (GAS) $15.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00
BOILER $35.00 ,FURNACE $35.00
CHIMNEY LINER $10.00 GAS DRYER $10.00
WORK $10 00 LGAS PIPING $10.00
DUCT
Number of fixtures @ $lo:oo � x $�to.�o = $ ro. �
Number of fi�ctures u�? $15.U0 � x$15.fl4 =$� �
Number of fixtures @ $25.00 x $25.00 = $
Nurnber of fixtures @ $35;04 x $35.E10 = $
State Surcharge = $ 5.U0
n�.rtakm►etrin,( �L Ti ed(1 MIl' Tntal =% �� .�
SIZEBTU
SIZEBTCT
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS UNIT FITTi �10.00
_POOL HEATER $35.00
VENTILATOR $15.00
THIS TS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCES5ED
I hereby apply far 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 Construcrion 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.
5IGNATURE OF APPLICANT �i�-�'� �� PRINT NAME KIJ i/� �rl s�t { DATE I � G ��
APPROVAL INSPECTORS SIGNATURE
PLEASE NOTE: S�PARATE ]
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977