P - 44193Building
Inspections
763-572-3604
763-502-4977 FAX
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
Permit No.`.
Received
Date
DATE �- ��� YOUR E-MAIL ADDRESS 5 C' rt GL!S� r+ C� r MPr� �i-�r i Gi�Sar-� . Lc, �-..,
srrE avnxESS '1 �'t'R S�vr, vha.�-,�,�t �
THIS APPLICANT IS: ❑ OWNER
PROPERTY x�: ��,,,, h,.� w�k', S
OWNER/ ADDRESS: ir'JG `� 53 mQhm��' s� crrSt �r�c�l�y STATEj�ZIP��a
TENANT PHONE: �t2'�j-�„�� --�r 3y
CONTRACTOR Co1v1P.�i' x.�1v1�: �.r e r es'Y ,-, P l� C..�
SUBMTT A COPY OF CONTACT PIItSON: S� ��r _ E ri(,�Scsr
YOUR STATE STATE LICENSE # �i� "L� �� �j =-I EXP DATE Co ��C�'' Z0)L?
LICENSE W1TH ,�DRESS: I�I;1 I LI � r-i �i Lr� �j E CI'TY 31Q.iln �i STATEJ�i ZIP�C C j�
APPLICATION pHONE
���--t�3— �t�`a�l� Fn�c Zcc��—��3���,tr,t�
PERMIT TYPE
�E oF woxx:
�SINGLE FAMILY ❑ TWO FAMII,Y
❑ NEW j� REPLACEMENT
❑ TOWNHOUSE
❑ ALTF.RATION/REMODEL
DETAILED DESCRIPTION OF WORK P� r�l�r.�? S• .rrx�c�
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO�
Equipment Inatalled MFG: MODEL: S1ZF/BTU
�u ;ie�
MODEL:
SIZF/BTU
MFG: MODEL: SIZFJBTU
A/C 525.00 _FIItEPLACE (GAS) $15.00 _GAS RANGE/OVEN 510.00
_AIR TO AIIt EXCHANGEER $15 FIItEPLACE (WOOD) $35.00 NEW GAS GRILL E 10.00
BOILER $35.00 =FURNACE 535.00 _GAS LJNiT H1'R � 10.00
_CfIIlvIl�iEY LINER S 10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. 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 ermit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case o�� w c,�i requir�s review and approval of plans.
SIGNATURE OF. APPLICANT
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
II�