P - 40104��u�lding
Inspect�ons
763-572-3604
763-502-4977 FAX
DATE �j
SITE ADDRESS _
THIS APPLICANT IS:
1@�i�C�IANICAI�
R�SID�NTIAI, APPLICr�'�'IOl�T
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOLR
�il Co � `�
❑ OWNER e]CONTRA
PROPERTY NAME:
OWNER/ ADDRESS
TENANT
PHONE:
��
0
Permit No.:
l�eceived By: ''L��
��,{� j�t�ilw+' U. � � � �
STATF,�'I�"LIP S S � .,j
CONTRACTOR con�mArrYrr.aME: CENTERPOINT ENERGY
susMITACOPYOF corrT.acTrExsorr: JOANN ZINKEN
YOUR STATE sT.a� LzcErrsE � BOND #�22013346 EXP DATE �8�20�2�1�
LICENSE WITH ADDx�ss: 9320 EVERGREEN BLVD SUITE B crrY COON RAPIDS sT.aTEMN z�55433
,APPL:CATION : - . _ _ _
PHONE _ '_Il��' � �� ' ��C, i_�._ FAX � �� -..'—% �' S �( ���.
PERNIIT TYPE SINGLE FAMILY ❑ TWO F?.ivIIL.Y
TYPE OF WORIt: � ��'�' ��PLACEMENT
DETAILED DESCRIPTION OF WORK �
i� �'�� CB� i � � �
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON 510.00 PER FLYTLi2E, EYCEPT WHERE NOTED. FIk°I'L�iES: (I1��ICATE TOTAL NUVIBER OF EACH BELO�i�
PROVIDE HEAT LOSS CALC'S PER D�IANUAL J 2006 ASHRAE H�.NDBOOK
Equipment Installed MFG: _ MODEL _ SIZEBTU
A/C $2�.00
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIhiNEY LINER $10.00
DUCT WORK $10.00
Number of fi�ctures' @ $10.00 �
Number of fix:ures @ $15.00
Number of fixtures @ $25.00
Number of fixtures @ $35.OQ
State Surcharge =
-- ------ --- --�`'�
MFG:
MODEL:
MFG: IvIODEL:
FIREPLACE (GAS) $15.00
_FIREPLACE (WOOD) $35.00
FURNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
x $35.0
SIZEBTU
SIZF/BTU
_GAS RANGE/OVEN $10.00
�EW GAS GRILL $10.00
GAS iJNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
0 = $_�;c�
0=$
0=$
0=$�
' S.00 �
'S � C�G �,: � 1 ib�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowled�e 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 applicatio ermit and rk is not to start without a permit; that the wo k will be in accordance with the
approved plan in the case of w k whic quires iew and approval of plans.
SIGNATURE OF APPLICAN �1/YI/1 PRINT NAME JOA N I NK a� ��/�I
APPROVAL INSPECTOR GNATURE DATE
PLEASENOTE:' EPARATE P t�t. REQUIRE FORBUILDING, ELEC I A MFoE�I��NICAL WORK
City of Fridley - �
, ilding Inspections Department
64 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977