P - 35323Building MECHANICAL Permit No..
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY C� R.��
%�3-5�2-4977 FAX EFFECTNE 1-1-2011
DATE l.�I {I YOUR E-MAIL ADDRESS
s�� aDDxESS I S,3 3� e� ne eo�- .
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY N�: i� ; � ,,• r Y�
owN�t/ aDn�ss: /5„�3 �}t�n�e �ri�' ci� : � srA zu>�
TENANT
PHONE:
corrrxACTOx co�arrY rr.v�: •-�` -
SUBMIT A COPY OF corrracTPExsox:dba Fireside Hearth & Home
License 20512060
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WTI'H �DRESS: Roseville, MN 55113 CITY STATE 7.II�
APPLICATION
PHOAIE FAX
PERMIT TYPE �SINGLE FAMQ,Y ❑ TWO FAMQ.Y ❑ TOWNHOUSE
TYPE OF WORK: �w o�c�Nr O ALTERATION/REMODEI.
DETAII,ID DESCRIP7TON OF WORK ` I��. `rt w t �' � `
FEES ARE BASID ON SiA.00 PIIt FIXTURE, EXCEPT WHII2E NOTID. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOR�
PROVIDE HEAT LOSS CALC'S PIIt MANLJAL �T 2A06 ASHRAE HAND�OOK.
EqaipmentInstalled MFG: ��1,!n/.(d MODEL: GpS/�"O ��,�,5 SIZFIBTU_�(n%r%
MFG: MODEL: SIZE/BT[J
MFG: MODEL: StZF1BTU
_A/C 525.� �FIRFPLACE (GAS) S15.W GAS RANGE/OVE23 510.00
_AIR TO AIR EXCHANGEER S15 FIREPI,ACE (WOOD) 535.00 NEW GAS GRILL S10.00
BOILER S35.00 FURNACE 535.00 _GAS UNIT FTTR EI0.00
Cii�IlJEY LINER 510.00 GAS DRYER 510.00 POOL HEATER 535.00
DUCT WORK 510.00 GAS PIPING 510.00 VENTII.ATOR 515.00
Nt�nccnn�r t� � �l�f:i1�? �c~���.41k}.�.g , � r F " `�.
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Nwnb�r of �'i�ct�es � SIS.UO _r�_,_,x $15.00 = $ � Srf �
Ntttnber of fixtures @ �25.00 x �25.00 = $
Number of fuctur� �a, �35.� x $35.00 = $
State Surcharge = $ , 5.00
FEE $4QOd Totai = $ "�' � �
THIS IS AN APPLICATION FOR A PERMIT-NOT V ALID 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 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 whi�ain quires review and approval of plans.
SIGNATURE OF APPLICANT _PRINT NAME_�,� � j n 1 f i S� L_ DATE ��
APPROVAL INSPECTORS SIGNATLJRE DATE
° i>L�AS� �C)T'�. �'Ai�TE. ii12 BUiI.�'iII�TG ` �CAI. ' ' ��'ti�` �'�Tt� i' ' ;
- City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977