P - 48061Building MECHANICAL
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
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SIT'E ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
YOUR E-MAIL ADDRESS
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❑ OWNER
NAME: t.t.-I�'E'.LL
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ADDRESS: I'iI g`�°'1 t n -�`t'��'L' -.
PHONE: �SZ� � �I-�' I �i1(„p
Pernut No.
Received
CONTRACTOR COMPANY NAME: �g� & H�mg� J,n i�, Inc.
SUBMIT A COPY OF corrTACT rExsorr: dba Fireside Heanh & Home
cens
YOUR STATE STATE LICENSE # ��nn u csirviour Af�P DATE
LICENSE W1TH ApDRESS: Roseville, MN 55113 CtTY ST.a'rE zrn
APPLICATION
PHONE FAX
PERMIT TYPE �SINGLE FAMILY ❑ TWO FAMILY
TYPE OF WORK: �NEW ❑ REPLACEMENT
DETAILED DESCRIPTION OF WORK �n s��l ( �;
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
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FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOVI�
PROVIDE HEAT LOSS CALC'S PER MANUAL T 2006 �SHRAE HANDBOOK.
EquipmentInstalled MFG: f}ea� �C��o MODEL: `>�-°��TiC'��-L=� SIZEBTU �� ���
A/C $25.00
AIR TO AIR EXCHANGEER $ I 5
BOILER $35.00
CHIMNEY LINER $10.00
DUCT WORK $10.00
MFG: MODEL:
MFG: MODEL:
[ FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
� _ GAS PIPING $10.00
SIZE/BTU
SIZE/BTU
GAS RANGE/OVEN $10.00
NEW GAS GffiLL $10.00
GAS UNIT HTR $10.00
_POOL HEATER $35.00
VENTILATOR $15.00
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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 codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a pernut but only an application fo a pe and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of al�.wo whi eq ires review and approval of plans.
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SIGNATURE OF APPLICANT�% T NAME1'O�-�n�Q/+z /�? E-� / DATE ��� !��/
APPROV
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977