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Inspections R�SID�NTIAI� APPI.,ICA�ION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �1'
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
"' � ( YOUR E-MAIL ADDRESS
:�'t 1 1�C,�e v��n0.S� a►� �, 1�
C]OWNER �CONTRACTOR
NAME: 1 $
ADDRESS: �,I� �EV1Ni.C�..STG�N �Ct
PHONE: � (,I�'J ^S_I � • � � (,p �
Permit No.: 2_«
IZeceived By:
.�,:: ,�, � q,
ATE"UVZIP:�
CONTRACTOR co�Arr�rrr�: CENTERPOINT ENERGY
susivtzT A coPY oF corrTacT rExsorr: JOANN ZI NKEN
YOUR STATE sT.a� LicErrsE# BUND #�22013346 EXP DATE 08�20�2�11
LicErrsE wiTx ADDx�ss: 9320 EVERGREEN BLVD SUITE' B c�TY COON RAPIDS sTATEMN z�r55433
.�PLicaTTOrr pHONE 763-757-6202 FAx 763-757-6701
PERMIT TYPE
TYPE OF WORK:
� SI�IGLE FAIvIILY ❑ TWO FAVIILY
❑ NEW � REPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK ��r+a� c�.�� rie w Q 0.S �mc�IC.�a�o ��cAaCe. �.00c�e.r�
1 •\... ✓ �c4� � .1 ..0 C n .r. � _ . _:... A
FEES ARE BASED ON 510.00 PER FI�YTLRE, ElCEPT WHERE NOTED. FIXTL-RES: (I1��ICATE TOTAL NUViBER OF EACH BELO��
PROVIDE HEAT LOSS C.ALC'S PER D4?urUAL J 2006 ASHR�.E HANDBOOK
Equipment Installed MFG: MODEL: SIZEBTU
MFG:
NIODEL:
SIZEBN
MFG: MODEL: SIZEBTU
A/C $2�.00 FIREPLACE (GAS) �15.00 K'iAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 _NEW GAS GRILL $10.00
BOILER $35.00 �FURNACE $3�.00 GAS iJNIT HTR $10.00
_CHIbfNEY LINER 510.00 GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 �GAS PIPING $10.00 VENTILATOR $15.00
Number of fixtures' @$10.00 �'x $10.00 --�$ l Q, b�
Number of fixtures,@ $15.00 x $15_00 = $
Number of fixtures @ $25:00 x $25.00 = $
Number of fixtures @ $35.00 x $35.00 = $ �
— �State Surcharge — $ SAO � �
(MINIMUM FE S40A ' Total = $ � �" • �d �
��
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building 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 per rt work is not t start without a permit; that the work will be in accordance with the
approved plan in the case of� wcXk which r� ires r'ew and�roval of plans. ' / _' �
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SIGNATURE OF APPLICANT
APPROVAL TNSPECTORS SI ATURE � (/ ` DATE
PLEASE NOTE: SEPARATE PERMI A D FOR BUTLDING, ELECTR .
of Fridley
, Bui nspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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