P - 37255Building MECHANICAL P��'t N°.:
Inspections RESIDENTIAL APPLICATI4N Received By:
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763-572-3604 CITY OF FRIDLEY � �� `
763-502-4977 FAX ����
EFFECTIVE i-1-2011
DATE I i2 I� YOUR E-MAIL ADDRESS
STI'EADDRESS ��J Z (YiG.�zr 1�p['�'1 �%,
THIS APPLICANT IS: ❑ OWNER �ON'['RACTOR
PROPERTY NAME: �c� r Cn n/; �F�,S � I��ICG
OwNE�t/ �D�ss: S�3 t 3 !� � i� ��1, e�� iJ �' ci� �: dF� c STATE 'LMI/rZIP
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PHONE: �n 1 e� • 5 O 1� y� �(p
CONTRACTOR COn�rnarrY NAME:
CONTACT PERSON:
SUBMIT A COPY OF �ba Fireside Hearth & Home
YOUR STATE STATE LICENSE # License 20512060 EXP vATE
LICENSE WITH �DRESS: Rnseville. MN 55113 CTCY STATE ZIP
APPLICATION 651 /633-2561
PHONE FAX
PERNIIT TYPE �SINGLE FAMILY 4 TWO FAMILY ❑ TOWNFIOUSE
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TYPE OF WORK• �NEW ❑ REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK j�.S .�,� �� G G s ; �s �I a c� j„ yG r� w�C� ti s �` �
FEES ARE $ASED ON $10.00 PER FIX'fIJRE, EXCEPT WHERE NOTED. FIXT(7RF.S: (INDICATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LOSS CALC'S PER MANUAL d 2006 ASHRAE HANDBOOK. .� �r � �,,,,/�
Equipment Installed MFG: �► �' � Lr ( u MODEL: ,t C s� c� 1� i; s�i3 SIZFJBTU _��(��_
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
_A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGF/OVEN $10.00
AIR TO AIR EXCHANGEER S15 FIREPLACE (WOOD) $35.00 NEW GAS GRILI. SI0.00
_BOILER $35.00 FURNACE $35.00 _GAS iJIVIT HTR $]0.00
CHIMNEY LINER $10.00 GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK 510.00 GAS PIPING 510.00 VEN'I'ILATOR SI5.00
Number of fixtures @ $10.�0 � x $10.00 = $ / D • vt�
Nwnber of fixtures @ $15.00 __1__ x $15.00 = S / S • �
Number of fi�ures @ $25.00 x $25.00 = $
Number of fiattures @$35.00 x$35.00 = S
State Surcharge = $ 5.00
FEE $40.OQ Total ° $ O , vD
THTS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 p it and work is not to start without a permit; that the work will be in accordance with the
approved pian in the case of all work which req ' revi and approval of plans.
SIGNATIJRE OF APPLICANT � T NAME �t/ i r� r(' 1 g��� DATE p �o I
APPROVAL INSPECTORS SIGNATURE DATE
PLEASE NOTE: SEPARATE PE RE UIRED FO BUII,DING, ELECTRICAL AND MECHANICAL WORK
City of Fridley
uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977