P - 50483Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ 7T�
SITE ADDR�SS '
THI3 APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
E-MAIL ADDRESS
❑ OWNER ,�CONTRACTOR
Permit No.:
Received By;
ADDRESS: S°�}C� G I3/'t/� �1 t r' Pp SS CtTY F�� �t' STA1'EN'�� ZIP 55y�
PHONE: ucnn�u p. uF1wA� �GFElAIA1 Al3iBC_ iN['_
coMrAx�rrAME: dba FIRESIDE HEARTH & HOME
CONTACT PERSON: �IC. BC0512060
STATE LICENSE #_
ADDRESS:
PHONE
�SINGLE FAMILY ❑ TWO FAMILY
�NEW O REPLACEMENT
DETAILED DESCRIPTION OF WORK i n s� � l�
EXP DATE�'- • - - -- - - - - - -- — -
� STATE ZIP,
FAX � �
❑ TOWNHOUSE
❑ ALTERAT'[ON/REMODEL
; rt o�a. � L i`n Str � u✓ G�' j��� C
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
EquipmentInstalled MFG: r��wlc,Po� MODEL: /�II�I�.3D-S� SIZE/BTU ����
MFG: MODEL: SIZEBN
MFG: MODEL: SIZF/BTU
_A1C $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 535.00 _FURNACE E35.00 GAS UNIT HTR $10.00
CHIMNEY LINER $]0.00 GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 �GAS PIPING $10.00 _VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 a11 work which requires review and approval of plans.
SIGNANRE OF APPLICANT ��- PRINT NAME �i n/���s ��� G DATE S.� / 2
APPROVAL
DA'
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977