P - 45675Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE i-i-zoii
Da� � d �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
�
YOUR E-MAIL ADDRESS
w - moo�e LAke l,r.
❑ OWNER �CON'I'RACTOR
Permit No.:
Received By:
Da�C1,��' d�
��
NAME:__j�a v�� io 1� 1
Avv�ss: 5 SS 9! �.✓�'►�+o�� L•�,�r Rdt cr� �i=�r.l �e.� STATF��[_ZIP,SS�/?�
PHONE: %Gt'3• S%%� /7Gi?
COMPANY NAME: kiea� & HomaTach�elagies�lns. '
CONTACT PERSON: ciba Fireside Hearth & Home
STATE LICENSE #�G SI.�01i O • EXP DATE ?700 N_ Fairview �ya
t-��seville, MN 55113
ADDRESS: CITY ,. STATE ZIP
PHONE FAX �
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: /t' �W � �PLACEMENT
❑ TOWNHOUSE
❑ ALTERAT'ION/REMODEL
DETAILED DESCRIPT'ION OF WORK i l�S� a I I�G S�.' rc� /�c L° w� L+s� S�� �� G
FEES ARE BASED ON $10.00 PER FTXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVf�
PROVIDE HEAT LOSS CALC'S PER MANUA J 2006 ASHRAE HANDBOOK ���,.�'�
EquipmentInstalled MFG: �� r� ; rc MODEL: I�M :^ %�p.� SIZE/BTU-��1�i�"�•=
MFG:
MODEL:
MFG: MODEL:
_A/C $25.00 FIREPLACE (GAS) $IS.W
AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00
BOILER $35.00 FUTtNACE $35.00
,CHIMNEY LINER $10.00 _GAS DRYER $10.00
DUCT WORK $10.00 �GAS PIPING $10.00
�t11C1t1�' O� �1X�tt1'�5 � $�$.� X .�2�,{:0 = �
I3."",�'
ctures @ $35.OU x $35.Q0 = $
ge = ` ` $ 5.44
f+EE �40.Q0) Total = � �� ���
SIZE/BTU
SIZE/BTU
_GAS RANGE/OVEN a10.00
NEW GAS GRILL $10.00
GAS UNIT HTR $10.00
_POOL HEATER $35.00
VENTII,ATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 wl�icth re ires view and approval of plans.
SIGNATURE OF APPLICANT
APPROV.
' PL�
PRINT NAME ,(��U i n� r � S��
TE
�� City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-49�7
�