P - 62691Building MECHANICAL Permit No.
Inspections RESIDENTIAI, APPLICATION Receivecl sy��''
763-572-3604 CITY OF FRIDLEY ���'�� "
763-502-4977 FAX EFFECTivE 1-�-zo>>
DATE � 'Z1— (L YOURE-MAILADDRESS /TeLh/�ynP� [TQ,Q/�J(�NL'�d'r►'�i �[J''�'�
SITEADDRESS ��DJ ��� � /(/F
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY NpME:
OWNER/ ADDRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR coMPANY NAME: dba FIRESIDE HEARTH & MOME
SUBMIT A COPY OF CONTACT PERSON: UC. BCOSI2OGO
YOUR STATE STATE LICENSE # EXP DATE 2700 FAIRVIEW AVENUE
LICENSE WITH ADDRESS: CITY � A'I'� ZIP
APPLICATION -�"j , ,
r�-�c;1�, rt�x
PERMIT TYPE '�' °""GLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
TYPE OF WORK: �Ew ❑ REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK ���,����p �.� �,�,ti., Gy ,�r�,e
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Installed MFG: �4.�v MODEL: D� q3 SIZEBTU �J �j �40
MFG: MODEL: S[ZE/BTU
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 UNIT HTR $]0.00
CHIMNEY LINER $10.00 GAS DRYER $] 0.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
Nurrtber �f �xiures � $10;00 ? x �10.04 = �
��iil'i�r c�#'�xtur�s (a�.$J,S:OtI x $15,60 = � '
Num�er of fixtures �ia �25':00 x $�5.0� = $
t�urnbe� of f�tures � �35;�� x $35.0� = $
State Surchar — ' $ 5.0
' ��
MIN�IYY�? ��E, $40,�0' atal = � �'
THIS 1S AN A LICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for i ding 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 whic requires iew and approval of plans.
SIGNATURE OF APPLICANT G� rT(i� PRINT NAM�d N.`"' ��7 0 ( DATE �`Z [� fZ
APPROVALINSPECTORSSIGNATURE DATE I {�
PLEASE NC)'I"E: �EFARATE R S R�Qfi JIRED FOF� BUILD�NG, ELECT AL ND MECHANI��'I: Vlx(7KK '
City of Fridley
B lding Inspections Department
64 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977