P - 46514Building MECHANICAL
Inspecrions RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX �c� i-i-zoii
DATE � 1 ( YOUR &MAII. ADDRESS
srrE nDnxESS __ 1�!v 7/ � wA--/
THIS APPLICANT LS: ❑ OWNER �ONTRACTOR
PROPERTY x�: n e
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TENANT 7/ �'wM crrY :
x
PHONF.� %l03 �S71- Q 70 3
CONTRACTOR
Peimit No..
Received By:' � �'��
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SUBMITACOPYOF CONTACI'PERSONw � ���i�slB��r�2OEO "��'�° �����j�� HEARTH & HOME
YOUR STATE STATE LICENSE # �� �-�C. BC0512060
LICENSE WITH ,e,DDRESS: 3 �� •STATE Z�
APPLICATION Pxo� 651.633.25� S- �� T'ii3
PERMIT TYPE
TYPE OF WORK:
�SINGLE FAMILY ❑ TWO FAMII,Y
�w ❑ REPLACEMENT
DETAII.,ED DESCRIPTION OF WORK i,
❑ TOWNHOUSE
❑ nt.�xnTtax�onst,
FEES ARE BASED ONI 510,00 PER FIXTURE, EXCEFT VVHERE NOTED. FIXTURES: (INDICATE TOTAL 1VUMBER OF EACH BELO'R�
PROVIDE HEAT LOSS CALC'S PER MANUAL 20 ASHRAE AANDBOOK.
FAuiPment Installed MFG: /�Cw.� A��� MODEL: ��� G 3O SIZElBTU �!/Y'�
MFG:
MODEL:
MFG: MODEL:
A/C 525.00 �FIREPI.ACE (GAS) $15.00
AIR TO AIIt EXCHANGEER S15 FIItEPI.ACE (WOOD) $35.W
BOII.ER $35.� _FURNACE 535.00
CHIMIVEY LINER $10.00 GAS DRYER 510.00
DUCT WORK 510.00 % GAS PIPING $10.00
SIZFJBT[J
SIZEIBTU
_GAS RANGFJOVEN 510.00
NEW GAS GRILL 510.00
GAS UTTIT HTR 510.00
POOL HEATER $35.00
VENTII.ATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that tfie work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand tivs is
not a permit but only an application for a t and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work which r uires reviqw and approval of plans. _
SIGNATURE OF APPLICANT
ALIN3PECTOR$SIGNATURE
dv.n f�ichl:e
City of Fridley
� ilding Inspections Department
l 'versity Avenue NE, Fridley, MN 55432
763-572-3604 FAX: ?53-502-4977
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