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?nsp�ctions �S���l�'I'��� ��'P�,��1��'��l'�I
763-572-3604 �I�`�' ��; �'RID����'
763-�02-4977 FAX �
EFFECTIVE I-1-_011
DATE � ` O� `'� �
SITE .ADDRE55
THIS A.DPLICA;V7' IS.
PROPERTY
O�JNER/
TENA�T
pl YOUR E-\2? IL ADDRESS
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❑ OV�'NER L CONTRACTOR
NAIvIE:
ADDRESS. 6 /� � S CITY
oun�.r� , � ��• �T�... lA � :� �
�er��?t No.:
Received Fy: � . ._
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Date��: �
z-�19N zr� 55 ya
Co:vT��.CTO� coNrn�.�.� N.a��: CE�f��RRQI�T E�E��Y - �
SUBn��iT.� CoPY or covr.4cr PE�onr: JCA!�N ZII�KEfd �,
�'oL�sTa.rE sT.��LLicL�.1sE-g0l�D 122Q133�-5 �;��.a�,� Q8/20/2011 �
L1�Etis� v,zTx ���;5: �320 E��F FG!��EN BLl�D SUI i E r3 c?T� COQN RAPIDS sra.r��� z�55433 '
APPLIGATION � � -Trz -•,,,•, �c� -7�� G-'t�t '
pHO�� ,-�-� —,���� :_�� -rto3-��s-Syoo
�� _ ;
� �
?C.t2V'IFT T�' P� �/� Si�IGLE F.4i��IILY ❑ T'�.r0 F?.i��� Y O TOW"v:iOliSE
Ti"�E�i� e��fl�: ^u�_��� ��D?.����;�-��1 ❑.�?T�naT�o?�;���to��L
D�TA��,�D DE�Ci�iF'TIO� OF �%,`OF.iC $ �.� Q °� �
iEES .yP.E B.-s.�ED O\` Si0.00 PER FLZTL''�:, EtiCFFT t�'I�Ei.E \QTLD. Fi,`�TLnES: (L'`�JIC.�.TE TOT_4L?�Z1iBER OF E.-"�C:i : ELO`V)
°P.O � �E :`r.lT LCSS C�S,C'S PER [�L=\L_,�.�j 60fi .-'�� "'t. � i-i`.e'��BOOik. --��y �'',�A„�
Equi:ment Inscailed n,iG: K, ll l� tvIOD�L. �s�•�T.1�1�'i�SSZ", TCJ `�� ��
�L"rG: Iv(ODEL: SLZ�B1ti _
�•I'"rG: .'v?ODEL:
A/C a�5.00 FIt"�`?LACE (G?.S) �li 00
__Ar� �'p �R c::Ci-La\GEER �I� _��pr e.Cc (Vr00D) 53�.00
�OiLEP. 53�-00 ✓'�LJP�vACL �35 G0
Ciu�i?v�Y L:�+'`��R S10.00 G.4S DR`. �R � lO.OG
�D� ;CT �z'GRI; � 10.00 G.aS ?i??N�� S t 0.00
�'1111'D°I G`:in�lli�5 �N �1�.�0 X ��l�.J� _ � _
'�umber of f;xrur�s @ $1�.00 x �1�.00 = �
ivumber o: fix?ures � .�2�.00 x �2�.00 = �
\urZber oi ixr�r�s � �35.00 \ x �3�.00 = � 3�. �
State Surc�arQe =
$ 5.00
iNl FEE �40.001 �i"otal = � `T U �
SI?EiB� U
GAS R?NGFIO��?V �10 �0
NcW G_4� GRILL i10 00
�GP.S L°NiT HTR � 10.00
�°OOL �=c.4?'�F 53�.00
'dc�TIL.�.T�R S 1 �.�JO
�S .AN .4PPLICATION FOR .4 PEP�'vIIT-NOT V?u.ID L1T:L PROC�SScD
I nereby apply for a building pe-r�it and I a;;kno���ledo� that the information above is complete and accu:ate; that the ���ork wiil be in
confonnance with the ordinances and codes of thz City of Fridle}� and �•ith tne _Niinnesota Construction Codes; that I understand this is
not a permit but or.ly an application for a permit and v,-ork is not to start without a permit; th�t the work will be in accordance with the
aooroved plan in the case of,a�l woykr-r�hich requi�es re� ie� and approval of plans.
SIG?�ATiJRE OF APPLICA�T
s�.a��PP.II�'TNA?vfE JO�f�N ZI�KEN DAic I�'�G/ /�
�.4PPROVAL INSPPCi'ORS ��?�ATLIRE DATE ✓" Z 7"% 2
PLEASE NOTE: S PARATE E i ARE REQliIRED FOR BUILDI:�G, ELECTRICAL AND MECHANICAL ��'ORK
Ciiy af Frid�ey
uiidina Inspectio�s Bep�a tr�ae�t
31 University Avenue NE, Fridley, MN »432
763-572-3604 FAX: 763-502-4977