P - 44564Building MECHANICAL Permit No.: � C
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Inspections RESIDENTIAL APPLICATION Received sy1!�/�.�
763-s�2-3604 CITY OF FRIDLE� DI��'�
763-5�2-4977 FAX EFFECTNE i-1-2011
DATE_�D �i ( I YOUR E-MAIL ADDRESS
srrE anD�ss o? l( S-f � v a r+ �.n �'� �.
THI3 APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY N,qME: e�v e tN d(�- 2��� s r'
�WNER/ .�wDRESS: �? � I S� � vs. r+ Ln CI'PY rrd11 e STATElt?�1ZIP 5��+ j
TENANT pxOrrE: 7�i 3• S"�? - 3 f 7� �
CONTRACTOR COMPANY NAME: h{e rkh & HoRle Tech[M. �GQLR. ��c• �'
SUBMTf A COPY OF CONTACT PERSON: dba. Flreside Hearth & Home
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YOUR STATE STATE LICEI3SE # EXP DATE upp N_ F�tirylaw Ave
LICENSE WITH ADDItESS: �Ty Roseville, MN 55113 STATE ZIP
APPLICATION pHONE FAX
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PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMII.Y O TOWNHOUSE
TYPE OF WORK' �W ��LACEMENT O ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �f �1 I(_�a� i; �C •� c,� �1 G a S�� �� �
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FEES ARE BASED ON 510.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELO'R�
PROVIDE AEAT LOSS CALC'S PER MANUAL 29� ASHRAE HANDSOOK
Equipmeirt Installed MFG: Il } n Ci 1 O MODEL: iMG� � SIZE/BN .3 �
MFG: MODEL: SIZEB'fEJ
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $i5.Q0 GAS RANGFIOVEN 510.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOIL,ER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
CHII�IlVEY LINER S I0.00 GAS DRYER $10.00 • POOL HEATER $35.00
�DUCT WORK $10.00 I GAS PIPING $10.00 VENTII,ATOR$15.00
'��1C1�" C�t� ��t�� � ���� . ;; � �"!`��.� � "�r .:�i�+Xli.ws . . , .: :
�U�" tl��X�YC!�5 f� �`r�S.�.:,,,�,z.X ��J.{�U ^' �'_ % �� .�
N�tt�ber uffi�ctures ('a� $25.U4 x $�S.UU = �
N�nb�a' of fixtur�� Qa $35.4d x�35 Ot! = 5
State Surchat�e = � 5.U0
FEE $4il.QU Tcrt�� =; $ . ��d. d/�?
THIS IS AN APPLICATION FOR A PERNIIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclmowledge 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 q''s review and approval of plans.
SIGNAZ'URE OF APPLICANT .�+� PRINT NAME Ji /► /'/'1 S�� DATE `O /i
APPROVAL IlVSPECTORS SIGNATURE DATE
PI.�*�:�`rE�?`I�: .��?'t��A., �.���'l�!�` 8�1�+�`r ,� 1�C��i'�I�.',c�`,�. ,
City of Fridley
uilding Inspections Department
31 Universitv Avenue NE, Fridlev, MN 55432
763-572-3604 FAX: 763-502-4977