P - 48232Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �T
SITE ADDRESS _
THIS APPLICANT IS:
�������C��
�2�SID�1�'I'�AI� APPI,ICAT��l�
CITY OF �RIDLEY
EFFECTNE 1-1-2011
YOL'R E-M.4IL ADDRESS
. l
❑ OWNER I�CONTRACTOR
PROPERTY NAME:
OWNER/ ADDRESS
TENANT r,
0
Permit No.;
Rece�����. "� ""
C3�
Date ec' •
5TA
...�,, js�`�' ! �)���_ �� �`P
CoNTR�CTOR co�An�NA�:_ CENTERPOINT ENERGY
strBNIITacoPYOF corrr,acTPERSOrr: JOANN ZINKEN
Youx sTaTE sTA� L�cENSE: BOND #22013346 E� Da� 08/20/2011
LtcENSE w�Tx ADD�ss: 9320 EVERGREEN BLVD SUITE B cirY COON RAPIDS sra-rEMN zIP55433
apPLlcaTTOrr PxoNE 763-757-6202 FA� 763-757-6701
PERMIT TYPE �SI�IGLE FAMILY ❑ TWO FAi�1ILY
TYPE OF VVORK: � �W ��pLACE�tENT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REIv[ODEL
FEES ARE BaSED ON 510.00 PER FLYTtiRE, E<l'CEPT ��'HERE �OTED. FIXTLRES: (I��ICATE TOTAL iV[J�IBER OF EACH BELO�V)
PRO�'IDE HEaT LOSS CALC'S PER DI.:.�tiAL J 2006 ASHRAE HAN�BOOI{.
Equipment Installed MFG: N10DEL: SIZEBTU
A/C $3�.00
AIR TO AIR EXCHANGEER � 15
BOILER $3�.00
CHIhINEY LI.NER 510.00
DUC"I' WORK �10.00
Number of fixtures @ $10.00 _
Number of fi:c:ures @ $1�.00
Number of fixtures @ $25.00
MFG:��.� MODEL: �,�.m C7� SIZEiBTU�T_QD�
MFG: MODEL: SIZEBTU
_ FIP.EPLACE (GAS) $I�.00 GAS RANGE/OVEN $10.00
FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10 00
�FURNACE $>j 00 GAS UNIT HTR $10.00
GAS DRYER $] 0.00 POOL HEATER $35.00
GAS PIPING �10.00 VETiTILATOR $1�.00
x $10.00 = $
x$1�.00=�
x $25.00 = $
Number of fixtures @, $35.00 � x$35.00 =$�`� . aD
State Surcharge =
FEE $40.00) Tota1= $
$ 5.00
� (��41I
THIS IS AN APPLICATION FOR A PERrifIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buildin� permit and I acl:nowledge 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 d with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not start without a permit; that the work will be in accordance with the
approved plan in the case of all work which r quires review and proval of (a �s. `e ��,� J��
SIGNATURE OF APPLICA PRINT I�iA�i]OAN�� I N KEN DATE �� ����
3PPROVAL INSPECTORS SIGNATLR�
PLEASE NOTE: SEPARATE
0
� �'�� �� ��� DATE �y
RMITS A RE IRED FOR BUILDING, ELECTRICAL AND MEC T
City of Fridley
B ding Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
�'7�
1�