P - 48137Building MECHANICAL Permit No.: " !a �
Inspections RESIDENTIAL APPLICATION R�eived By:
763-572-3604 CITY OF FRIDLEY Date �R�'� ���' �
763-502-4977 FAX �cT� i-i-ZOii
DATE l 3 II YOUR E-MAII� ADDRESS
srrE nnnxESS g�O /�1 vr� �c L�,k c r. wcs f
THIS APPLICANT IS: ❑ OWNER CONTRACTOR
PROPERTY x�: � �,,,. �„� .� �/C�
OWNER/ ADDRESS: SAO eDIC , L.a/�C Q P. CITY F�ro��a� STATE�/�IL[Pti��+
TENANT PHONE: iI �',i- � 01- 2�.77
OGIES INC.
CONTRACTOR co�Arnr xaME: �+ba FIRESiDE HEARTH & HOME
SUBMIT A COPY OF �NTACT PERSON: UC. BC0512060
YOUR STATE STATE LIG'ENSE # � Dnrs2700 FAIRVIE
LICENSE WTfH �ggss: ci�%5 � STATE ZtP
APPLICATiON
PHONE FAX � �
PERMIT TYPE �SINGLE FAI�IIL.Y O TWO FAMII.Y ❑ TOWNEIOUSE
TYPE OF WORK: ���' o ttEp[.ac�t�rrr � ALTIItA'IiONRiEMODEL
DETAILED DESCRIPTION OF WORK i I Gsa t Iwc t � a ` e
f0 wtr /d�t
FEES ARE BASID ON S1�.08 PIIt FIXTURE, EXCF�T WHERE NOTF.D. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BEIAR�
PROVIDE HEAT LOSS CALC'S PER MANU J Z9A6 ASHRAE AANDBOOK.
Equipment IAStalkd M�G: � i,I D MODEL: t�► G ,3 � ST7FJBTIT
MFG: A�DEL: SIZFdB1i3
MFG: MODII.: SIZElBN
A!C 525.00 � LACE (GAS) 515.00 GAS RAI3GFJOVEN SI0.00
AIR TO AIR EXCfiANGEER S15 FIREPI.ACE (WOOD) 535.00 NEW GAS GRILI. 510.00
BOII.ER 535.00 F[7RNACE S3i.00 GAS LJNIT IiTR 510.00
Ci�vvINEY LINER 510.00 GAS DRYIIt 510.00 FOOL HEA7ER 535.00
DUCT WORK S10.00 GAS PIpING 510.00 VENIII.ATOR SI5.00
� i�:��'':3�(• i�$��i��.��+"�r �RJt���!# ��r �^�, �` <:v lv:+m �'r�, g�' ��v ,� ..
:§y : ,. �� t ;�
N�€tbel fif S�►n'CS +� Sr1S.Q0 � X'.�15.(1Q =� J,� �
Number of iuchaes @$25.U� x 525.00 =�
Number flf fixhuc.s � $35.00 x $35_(l0 = �
State Surcharge = $ S.ilO .
FEE S4Qi1� Totai =$ � t!?�
THIS IS AN APPLICATION FOR A PERMIT-NOT V ALID UNTII. PROCESSED
I hereby apply for a builcling permit and acknowledge that the information sbove is complete and accurate; tl�at the work will be in
conformance with tbe ordinances and code of the C' of Fridley and with tt�e Minnesota Construction Codes; that I understand tl�is is
not a permit but only an application for a rk is not to start wid�out a pemiit; tbat the work wiil be in accordance with the
approved plan in tl�e case of all work which ' es view and approval of plans.
SIGNATURE OF APPI ICANT .�.� PRINT NAME�t�tJ//1 /` /! S�7 �� `' ATE o7 3/�
APPROVALINSPECTORSSIG DATE
��.� s�' �€� �%ti� u�" "`'
City of Fridley
' ding Inspections Department
1 University Avenue NE, Fridley, MN 55432
'763-572-3604 FAX: 763-502-497�
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