P - 42758Building MECHANICAL Permit No.:
Inspections RESIDENTIAL APPLICATION Received By: �,.
763-572-3604 CITY OF FRIDLEY �����1 ��0 0
763-502-4977 FAX EFFECTIVE 2-19-09
DATE� / I!7 YOUR E-MAIL ADDRESS
SITEADDRESS �Z �-
THIS APPLICANT IS: ❑ O R �CON1'RACTOR
PROPERTY N,�ME: lja �-� J� :� 1, in o n vt
OWNER/ ApDRESS: � V �l�j �(n/wy N� � CITY /'�
TENANT � � �s�i/e y sTnTF�Nzir;��
PHONE: ��j�',j%I' g%'rJ..Z
CONTRACTOR Co�.�tv�trr�: ��'
SUBNIIT A COPY OF CONTACT PERSON: dba Fireside Hea�th & Home
�cense 2051Z060
YOUR STATE STATE LICENSE #��00 N F�irvie�a J'�ve EXP DATE
LICENSE WIT'H qDDRESS: Roseville, MN 55113 CITY STATE ZIP
APPLICATION
PHONE FAX
PERMIT TYPE � SINGLE FAMILY ❑ TWO FAMILY ❑ TOWNIIOUSE
TYPE OF WORK: �EW ❑ REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRTPTION OF WORK f �L< / a ;� ��+ << n !' �" w G� S �•�� C
FEES ARE BASED ON SI0.00 PER FIX1`URE, E�CE WHERE NOTED. FIXTURES: �IC�A-T�'E �TO�,TAL NUMBER OF EACH BELO�
Equipment Installed MFG: s. !�, s. �- D!' MODEL: ( jf �'�3� ' f' P SIZEBTU �
_ �
MFG: MODEL: SIZEBTU
MFG_ MODEL: SIZF/BTU
A/C 525.00 �FIREPLACE (GAS) 515.00 GAS RANGE/OVEN 510.00
AIR TO AIR EXCHANGEER S15 iFIREPLACE (WOOD) E35.00 NEW GAS GRILL 510.00
BOILER 535.00 FURNACE 535.00 GAS iJIJIT HTR �10.00
CHIMNEY LINER �10.00 GAS DRYER 510.00 POOL HEATER 535.00
DUCT WORK �10.00 �GAS PIPING SI0.00 VENTILATOR 515.00
N�t� ofs� @ sio.� a X$lo.� _$ a�. �
Number of fixtures @ $15.00 x $15.00 = $
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 x $35.00 = �
State Surcharge = $ S �-5�---
FEE $35.50 Total = $ �. G�'T,
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJNTII., PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that �e 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 which requires review and approval of plans.
SIGNATURE OF APFLICANT ���� PRIN'T NAME /C �1/I /1 I� P i �L �� C DATE__ ���, �
.
PLEASE NOTE; SEPARATE PERMITS ARE RE UIRED FOR BUILDING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University �enue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977