P - 40102Building
Inspect�ons
763-572-3604
763-502-4977 FAX
DATE � ` 3 � 1 �
SITE ADDRESS I `D
THIS APPLICANT IS:
. .
_
RESID�NTIAI, APPLICATI01�1
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
I�• U :
PROPERTY NAM�: �
OWNER/ ADDRESS:,
TENANT
runrrF• �i
E-MAIL ADDRESS
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� ��. CITY �r�di�-'r-
Pemlit No.: %U � �
I�eceived By; ��
Da��' �
CONTRACTOR co�Ax�NAME:_ CENTERPOINT ENERGY
sustvIIT a coPY oF corrTACT PExsorr: JOANN ZI NKEN
YOUR STATE sTa� LlcErrsE � BUND �22013346 EXP DATE OH�ZO�ZO11
LzcENSE vv�Tx ADDx�ss: 9320 EVERGREEN BLVD SUITE B crrY COON RAPIDS srATEMN z�r55433
apPLlcA�orr pxoNE 763-757-6202 FAx 763-757-6701
PERMIT TYPE
TYPE OF WORK:
DETAILED DE
FAMILY ❑ TWO F.Ai�IILY
❑ NEW ,��2EPLACEMENT
ON OF WORK�,Pn�C��
❑ TOWNHOUSE
O ALTERATION/REMODEL
FEES ARE BASED ON �10.00 PER FI�YTtiRE, EYCEPT WHERE NOTED. FIXTL-RES: (Ir�ICATE TOTAL NUVIBER OF EACH BELO�t�
PROVIDE HE.aT LOSS CALC'S PER b'I�rUAL J 2006 ASHR4E FL�.NDBOOK
Equipment Installed MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
MFG: NIODEL: SIZEBTU
_A/C $25.00 _FIREPLACE (GAS) $I5.00 _GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.�0
_ _$�)ILER $3�.00 _FURNACE $3�.00 _GAS LJNIT HTR $10.00
I�CHIbINEY LINER $10.00 _GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
Number of fiactures @ $10,00 �_ x $10.00 = $ (� � ��
Number of fixtures @ $15.00 x $I5.00 = $
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures $35.00 x $35.00 = $ �
@ . �
State Surcharge ' $ � 5.00 �
(MINIMUM E $40.00) ta1= , �
THIS IS AN APPLICA fL6FiFOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a btildin' permit and I acknowledge that the information above is complete and accurate; that the work will 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 appli� ion for a permit and wor is not to start without a permit; that the work will be in accordance with the
approved plan in the case of 11 o hich requi s rev' and approval of plans.
. /�
SIGNATURE OF APPLICANT i�I PRINT NAME JOA N N CEN D TE-��'�( I�
APPROVAL INSPECTORS S AT � DATE
' PLEASENOTE: S ARAT __ _ S ARE REQUIRE OR BUILDING, ELECTRI AL` ND MECHANICAL WORK
City of Fridley
j° Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977