P - 42157Building 1�✓I�C�ANICA� P��it N°.: �
Inspections RESIDENTI�L APPLI�C'ATION Re�e�Ved By:
763-572-3604 CITY OF FRIDLEY f��R����--�-4 j
76J-5�2'-4977 F`�X EFFECTIVE 1-1-2011
DATE 1 YOUR E- IL ADDRESS
SITE ADDRESS � U �
THIS APPLICANT IS: C] OWNER e3CONTRACTOR
PROPERTY NpME
OWNER/ ADDRESS: — CITY � STAT ZIP 3
TENANT ^r2
PHONE: —� OG-c�
CONTRACTOR coMrarrYN�: CENTERPOINT ENERCY
SUBMIT A COPY OF corrrACT PExsoN: JOANN ZI NKEN
YOUR STATE STATE LICENSE # BUND #ZZO1334G E}{p DA'i'E �8�2��2�11
LICENSE WITH ,d,DD�ss: 9320 EVERGREEN BLVD SUITE ° B ci� COON RAPIDS sra�MN z�55433
APPLICATION pHONE 763-757-6202 F,� 763-757-6701
PERMIT TYPE �GLE FAMILY ❑ TWO FAIvIILY ❑ TOWNHOUSE
TYPE OF WORK: � �W �PLACEMENT ❑ ALTERATION/REMODEL
�
DE AILED DESCRIPTION OF WORK
FEES ARE BASED ON 510.00 PER FLYTLRE, EYCEPT WHERE NOTED. FIkTLTfiES: (INDIC ATE TOTAL NUNIBER OF EACH BELOWj
PROVIDE HEAT LOSS CALC'S PER MAriUAL J 2006 ASHRAE HAND$OOK
Equipment Installed MFG: MODEL: SIZEIBTU
MFG: MODEL: SIZE/BN
MFG: IvfODEL: SIZE/BN
A/C $?5.00 _FIREPLACE (GAS) $15.00 `GAS RANGEIOVEN �10.00
AIR TO AIR EXCHANGEER S 15 _FIREPLACE (WOOD) 535.00 ,NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTTt $i0.00
CHIhINEY LINER SI0:00 I GAS DRYER $10.00 �POOL HEATER $35.00
DUCT WORK $]0.00 GAS PIPING $10.00 �VENTII.ATOR $15.00
Number of'fixtures' @ � 10.00 x $10.00 = $ '
Number of fixtures @ $15.00 x $15.00 = $
Number of fixtures @ $25.00 x $25.OQ = $
Number of fixtures @ $35.00 x $35.00 = $
State Surcharge = ' $ 5.00
MINIMUM FEE $40.00 Total = $ .Q�. �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I-hereby apply for_abuilding permit and I acknowledge that the informatiAn-above is complete-and accurate; that the-work willbe in- -- - -----
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construcrion Codes; that I understand this is
not a permit but only an applica on r a permit and work is not to start without a permit; that the work will be in accordance with the
approved ptan in the case of a11 work �h re uires review and approval of plans.
SIGNATURE OF APPLIC � r PRiNT NAME DATE-��;fG�K'�.e-[_L--
' ' /
APPROVAL INSPECfORS SI ATURE DATE
PLEASE-NOTE: `SEPARAT S ARE RE UI D FOR BUILDING, ELE , IC AND'MECHAMCAb WORK
City of Fridtey
, Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977