P - 36957Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �
SITE ADDRES �
THIS APPI.ICANT IS
PROPERTY
OWNER/
TENANT
) Q K C /M'1 t,
❑ OWNER
NAME: �) u /' i
YOUR E-MAII. ADDRESS
s�o n iJ�'. F� G�
�ONTRACTOR
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PHONE: 7 i/,� � S7� � ��'1 �p
CITY r/' �` � �C
Permit No.:,
Received By:
���eC��
STATE�/JL/IP��
CONTRACTOR CoMP�Y x.�: ...�
corrrnc�r PExsorr: ea �
SUBMIT A COPY OF RS dba �ir��ida Hearth & Home
YOUR STATE STaTE LICENSE # Exp DATE License 20512080
LICENSE W1TH �DRESS: CITYpns�ville. MN 55113 � STATE ZIP
APPLICATION 651 /633-2581
PHONE FAX �
PERNIIT TYPE �SINGLE FAMILY ❑ TWO FAMILY � TOWNFIOUSE
TYPE OF WORK: J`��w o x�.nc�rrr ❑ ALTERAITONlRF.MODEL
DETAIL.ED DESCRIPTION OF WORK � 6�� t� �� �� � S �
FEES ARE BASEU ON 510.90 PER FIX1'[TRE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVl7
PROVIDE HF.AT LOSS CALC'S PER MANU 2006 ASHRAE HANDBOOK
E4wPmentb�sulled MFG: ao�Ca �; r�C. MODEL: �� 1 I � S3ZEJBTt7 V
MFG: MODEL: SIZEJBN
MFG: MODEL: SIZFJBTU
_A/C 525.00 —TFIRE.PLACE (GAS) 515.00 GAS RANGE/OVEN 510.00
_AIIi TO AIR EXCHANGEER S15 FIREPI,ACE (WOOD) 535.00 NEW GAS GRILI. 510.00
BOII,ER 535.00 FURNACE 535.00 GAS iJNIT H'TR SI0.00
CiIIIvIIdEY LINER 510.00 GAS DRYER SI0.00 POOL HEATER 535.�
DUCT WORK 510.00 �GAS PIPiNG 510.� _VENTII.ATOR 515.00
�1�iD�fCI O� �iXi�HCS ,�1,, ���.� � X �15.� = � � • �
N�mnber of fixteses @ $25.00 x $25.W = $
Nnmber of fixhues (�7a, $35:00 x S35.fl0 =$
State 5urcharge = $ 5.00
�7►���'�1IMUM FE� `540.00) Tatat = $ ��d • �'�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID 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 tlus is
not a permit but only an application for a perm' an work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of sIl wo k � h re uires r view and approval of plans.
. t,
SIGNAI'CTRE OF APPLICANT �—� PRINf NAME KC 1% �/� �i S� h C / DATE 7 / � _
... � /!/l� � /G7 �
APPROVALINSPECTORSSIGNATURE
PI.E.l4$�? 1�U'T�: sEF�AR�!'i"E 1
t
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-5?2-3604 FAX: ?63-542-497?