P - 40101Building
Inspections
763-572-36Q4
763-502-4977 FAX
DATE � � 3 I � I (
SITE ADDRESS �
THIS APPLICANT IS:
1/ ����►.�_'
R�SII��l�T'I'�AI, APPI�ICA'TION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOL'R E-MAIL ADDRESS
r`�nu.t' �S� NE
❑ OWNER L•]CONTRACTOR
PROPERTY NAME: � e�/1 !
OWNER/ ADDRESS: �0��� �("
TENANT pHONE: ,�A?J `SZ I ' � u
Permit No.:
I�eceived By; %V �l
Date�'�: ���
STATE�i�LIP
CONTRACTOR co�rArr�N.a�: CENTERPOINT ENERGY
st1BMIT A coPY oF corrT.acT PExsorr: JOANN ZINKEN
YOUR STATE sTa� LlcErrsE � BOND �22013346 EXP DATE OH�ZO�ZO11
L�cErrsE vv�Tx ADDx�ss: 9320 EVERGREEN BLVD SUITE B ciTY COON RAPIDS srArEMN ztr55433
aPPLica�orr PxoNE 763-757-6202 FAx 763-757-6701
PERMIT TYPE I�.SINGLE FAMILY ❑ TWO FAIvIILY
TYPE OF WORK: I � �W �PLACEMENT
DETAILED DESCRIPTION OF WORK
❑ TOWNi30USE
❑ ALTERATION/ftEMODEL
FEES ARE BASED ON 510.00 PER FLYTtiRE, EYCEPT WHERE NOTED. FIXTL1tES: (I1��ICATE TOT9L NUMSER OF EACH BELOW)
PROVIDE HEAT LOSS CALC'S PER Ati�.NU J 2006 ASIiRAE FL�NDBOOK
Equipment Installed MFG:��_ MODEL: N' b5 SIZEBTLT �J�i�%��% Q�
MFG: MODEL: SIZEBTU
MFG: NIODEL: SIZE/BTU
_A/C $2�.00 _FIREPLACE (GAS) $1�.00 GAS RANGElOVEN $10.00
_AIR TO AIR EXCHANGEER $15 F� PLACE (WOOD) $3�.00 _NEW GAS GRILL $10.00
_BOILER $35.00 ✓FURNACE $35.00 GAS LJNIT HTR $10.00
CHIhINEY LINER $10.00 GAS DRYER $10.00 _POOL HEATER $3.i.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
Number of fixtures' @ $10.00 x $10.00 = $
Number of fixtures @ $15,00 x $15.00 = $
Number of fixtures, @ $25.00 x $25.00 = $
Number of fixtures @ $35.00 � x $35.00 = $ �J���'
State Surcharge = ' $ 5.00 �/j'7 _
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(MINIMUM E $40.00) otal ��.�,._�
TION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply �lding 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 application for a ermit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of a or hich qu' revie and approval of plans.
SIGNATUREOFAPPLICANT , PRINTNAME 30ANN ZINKEN DATE
� / /�
.4PPROVAL INSPECTORS SI ATURE DATE
' PLEASE NOTE: SEPARATE , ARE REQUI OR BUILDING, ELECTRICAL AND MECHANIGAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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