P - 39384Building MECHANICAL Permit No.: ��+�I -=� 1
Inspections RESIDENTIAL APPLICATION Received By: ��� �`
763-572-3604 CITY OF FRIDLEY Date��:�� _,��� j
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE -1/Lv � l l YOUR E-MAIL ADDRESS
SITE ADDRESS �i�9 .jr � / '�-'� AV L° /U �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY N,aME: �oc► � e o�► I
E� � nvn�ss: (pF �5'9 t'� /4v� �/. F ci� �• STA'I'F�"J/A ZIPj�
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CONTRACTOR CO�ANY NAivtE: . ..
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SUBMIT A COPY OF CoNTACT rERSON: �ba Firesi�a Hearth & Home
YOUR STATE STATE LICENSE # License 205i 2060 EXP DATE
LICENSE WITH ADDRESS: Roseville, MN 55113 CITY STATE ZIP
APPLICAT'ION 651 /633-2561
PHONE FAX
PERNIIT TYPE �SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNIIOL7SE
TYPE OF WORK' ��W � �PLACEMENT ❑ ALTERAT'ION/REMODEL
DETAILED DESCRIPTION OF WORK � n3-� �. �% �>a S/" �/' c��q'« f.�/�� ti 5 �i n e
FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL 1ViTMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUA J 2,Ly OQ6 As ,��RAE HANDBOOK '-��'�1�—
Equipment Installed MFG: � C 4+ n 1 D MODEL: I O M o� SIZF/BTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
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 FURNACE $35.00 GAS UNTI' HTR $10.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 �GAS PIPING $10.00 VEN1'II,ATOR $15.00
zv�►t�r ot��� @ �io.00 X $io.vo = $ o �
Number of fiactures @$15.� f x$15.00 =$ / S. �
Number of fixtures @ $25.00 x$25.00 = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = $ 5.00
�E �ao.00 To�i = $ yo•�
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 Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a pe ' d w k 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 require r iew and approval of plans.
SIGNATIJRE OF APPLICANT PRINT NAME �� r� /'� �� DATE % f
APPROVAL INSPECTORS SIGNATURE DATE
PLEASE NOTE: SEPARATE PE RE UIRED FOR BUII,DING, E AL AND MECHANICAL WORK
City of Fridley
' ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977