P - 45275Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `O` � 'i ` ` (
SITE ADDRESS �' OO
THIS APPLICANT IS:
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CITY O�' FRII)LEY
EFFECTIVE 1-1-20ll
YOL'R E-MAIL ADDRESS
❑ OWNER I�CONTRACTOR
PROPERTY NAME: �G
OWNER/ ADDRESS:
TENANT
6 CITY
Permit No
I�eceived By:
D�V�9 "i.t
TAT� �! �LIP
CONTRACTOR co�a,rrxrr.aME: CENTERPOINT ENERGY
strB�T A copY oF coNTACT PERSOrr: JOANN ZINKEN
YOUR STATE sTa� LicErrsE� BOND #22013346 EXP DATE �8�2��2�11
LlcErrsE wlTx ADD�ss: 9320 EVERGREEN BLVD SUITE' B ciTY COON RAPIDS sTa�MN z�55433
APPLICATION pHONE 763=� �� °SyCit� FAX 763• �gJ -����
PERMIT TYPE
TYPE OF WORI�:
�SNGLE FAMILY ❑ TWO F?.ivIILY
❑ NEW `j�REPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILE D SCRIPTION OF WORK �""���-e.,,�� ��Cp l� �•e �-!.t ✓/�1GG� -C Qrld Q% r`
�d ��� �i OVI tC✓' T
FEES ARE BASED ON $10.00 PER FL�TIIRE, EYCEPT WHERE NOTED. FI?XTtiRES: (INDICATE TOTAL NUVIBER OF EACH BELO��
PROVIDE HE�.T LOSS CALC'S PER �I�1,NU J 2006 ASHRAE I�iANDBOOK �� Q DO
Equipment Installed MFG: ��r r i� r MODEL: ��� SIZEBTU I
MFG: � tCl� MODEL: �'1 �L�� �//Z"l SIZEBN ON ��
MFG: IvIODEL:
�A/C $2�.00 FIREPLACE (GAS) $15.00
AIR TO AIR EYCHANGEER $15 FIREPLACE (WOOD) $35.00
_BOILER $35.00 1FURNACE $35.00
CHIhfNEY LINER $]0.00 GAS DRYER $10.00
DUCT WORK $10.00 GAS PIPING $10.00
Number of fixtures @ $10.00 x $10.00 = $
Number of fi;�:ures @ $15.00 x $15_00 = $
Number of fixtures @ $25.00 � x $25.00 = $ S . �
Number of fixtures @ $35.00 � x $35.00 = $ �� • ��
State Surcharge = ` $ 5.�0
(MINIMUM FEE'$40.00) `Total = $ �'�+ 0�
StZEBTU
�GAS RANGE/OVEN $10.00
_NEW GAS GRILL $10.00
GAS I1NIT HTR $10.00
POOL HEATER $3�.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNfIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wili 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 applic 'on a permit a� d�vqo�is not to start without a permit; that the work will be in accordance with the
approved plan in the case of orlt�hi rect s�r �v and aooroval of olans.
SIGNATURE OF APPLICANT
APPROVAL INSPECTORS
` PLEASE NOTE:' S
�UIR�D FbR BUILL
City of Fridley
$uilding Inspections Department
� University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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