P - 42763Buildang
Inspections
763-572-3604
76�-502-4977 FAX
DATE 1 Y� j Z? I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
�l
l�✓I�C�iAlv��1��
��SIDENTI�L APPLICATION
�ITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
NAME:�_���- " !�
ADDRESS: � � �� C�
PHONE: � I t^Y�] • � 35 �
ADDRESS
CITY
Permit No.:
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Date Rec'd:
STA
S
CoNTR�CTOU co�A�rr.aME: CENTERPOINT ENERGY
sustvffTacoPYOF corr-rnc-rPExsorr: JOANN ZINKEN
YOUR STATE sra� LicErrsE � BOND #�22013346 EXP DATE �8�20�2�11
LicErrsE w�Tx AnD�ss: 9320 EVERGREEN BLVD SUITE B ciTY COON RAPIDS sra�MN zIP55433
aPPLICaTTOrr PxoNE 763-757-6202 F�� 763-757-6701
PERMIT TYPE
TYPE OF WORK:
DET
� SNGLE FAMILY ❑ TWO FANIILY
�NEW ❑ REPLACEMENT
OF WORK
❑ TOWNHOUSE
� ALTERATION/REMODEL
FEES ARE BASED ON S10.00 PER FLYTLT2E, ElCEPT �'HERE NOTED. FIXTLRES: (In�IC�TE TOTAL NUI�tBER OF EACH BELO�V)
PRO�TDE HEAT LOSS C�I,C'S PER A'I:INUAL J 2006 ASHRAE H.4NDBOOK
Equipment Installed MFG: IvIODEL: SIZEBTLT
MFG:
NIODEL:
SIZE/BTU
MFG: MODEL: SIZE/BTli
A/C $25.00 _FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
_AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOII.PR $3�.00 FURNACE $3�.00 GAS UNIT r1TR $10.00
CHIhINEY LINER $10.00 irGAS DRYER $10.00 POOL HEATER $3�.00
DUCT WORK $10.�J0 GAS PIPING $10.00 VENTILATOR $15.00
Number of'fixtures'@ $10.00 � x$10.00 =$ 1"� �`
Number of fixtvres @ $15.00 x $15.00 = $
Number of fixtures @ $25.00 x $25.�0 = $
Number of fixtures @ $35.OQ x $35.00'= $
State Surcharge = $ 5.00
(MINIMUM E $�0.00) otal = $ � � �
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby. apply for a buildin� permit and I acknowledge that xhe information above is complete and accurate; that xhe work witl 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 application for a permit and work is not to start without a permit; that the work wili be in accordance with the
approved plan in the case of wo which requires revie and proval of plans.
SIGNATURE OF APPLICANT ��'�� �y�RINT�Ar� JOANN ZINKEN � i DATE p !�
DATE T
PLEASE NOTE: SEI�ARATE PERMI UIRED FOR BUILDING; ELEC'T�ICA AND
City of Fridley
, uilding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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