P - 42171Building MECHANICAL Permit No.:
Inspections RESIDENTIAL APPLICATION Received By: �C�!°� �
763-572-3604 CITY OF FRIDLEY �j ���-�� ��
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE 0�.� YOUR E-MAIL ADDRESS
SITE ADDRESS �/ O � ,S�~ .S �� /�� E.
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY NAME; %�p ,n � k(« n�� r µ o( �
� N�� ADDRESS: �O�OI 5';G S�. /�,/. E CITY t'�':o��eY STATE�IP SS
PxorrE: 7103 • 5 7�- 3 0lo y
CONTRACTOR CoMPANY NAME: M ar�h � Home rar.nnolnaies. Inc. '
SUBMIT A COPY OF corrrACT PExsoN: dba Fireside Hearth 8� Home
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YOUR STATE STATE LICENSE # EXP DATE 270o N. Fairvisw Ave.
LICENSE WITfI �Dggss: � RoseQ'lle, MN 5511 STATE ZIP
APPLICATION PHONE FAX —�������-- "�
PERNIIT TYPE J�SINGLE FAMILY C] TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK• ��W � �PLACEMEN'C ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK _ J n�� c 1 I �S � r< A I A c� w� G� s I��— e
FEES ARE BASED ON 510.00 PER FIXTiJRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVi7
PROVIDE HEAT LOSS CALC'S PER MANUA J 2086 AS� E HANDBOOK. �/
Equipment Installed . MFG: t� ���+' o MODEL: �� C t.1� SIZE/BTt7 7 �T
MFG: MODEL: SIZEBTU �^
MFG: MODEL: SIZE/BTU
A/C �25.00 FIREPLACE (GAS) 515.00 GAS RANGFJOVEN 510.00
AIIt TO AIR EXCHANGEER S15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL 510.00
BOII.ER $35.00 FURNACE �35.00 GAS tINIT HTR 510.00
�CHIMNEY LINER 510.00 _GAS DRYER SI0.00 POOL HEATER 535.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR �15.00
�`�� � �ic�at� � �.� �� �.' � ' � �� ���� � � _�
� � � ��„ ,;t� ��
rru,�� of� �$1s.ao r x�is.00 = s ls". �
Number of fixt�u�es @ $25.00 x �25.00 = $
Number of f�tures @ $35.00 x $35.00 = $
State Surcharge = $ 5.00
FEE 540.00 Tota1= $ y0 • �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN'I'IL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 to start without a permit; that the work will be in accordance with the
approved plan in the case of all work v�tht r ires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME C✓� r1 � r� �� DATE � Z 2 I
V
APPROVAL INSPECTORS SIGNATURE DATE
�L�s� rro�. s��►� r� ur�n Fo� �uu��� ,
� City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-5'72-3604 FA.X: 763-502-4977