P - 43890Building
Inspections
763-572-3604
763-502-4977 FAX
DATE i U � !I � �
SITE ADDRESS �L)
THIS APPLICANT IS:
l��I�C�$1�NICAI,
�SID�N'I'IAI� APPLICA'�'ION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
E-MAIL ADDRESS
�...OV�� t"e � \o lrl
Q OWNER L7CONTRACTOR
PROPERTY NAME: K• 1/� F' t
OWNER/ r1� �^� Q�
TENANT �DRESS: ��y
vun�• 'i � �C • �'1'1..
CITY
Permit No.: a� � I ('G
Received By:�
����e��S-. . . ,, ,� j
CONTRACTOR co�rearrYrrar�: CENTERPOINT ENERGY
SUBMIT A COPY OF corrrACT p�xsorr: JOANN ZI NKEN
YOUR STATE sTA� LicErrsE # gOND #22013346 EXP DATE �8�2��2011
LICENSE WITH ,�Dx�ss: 9320 EVERGREEN BLVD SUITE ° B' crrY COON RAPIDS sra�NlN z�55433
APPLICATION PHONE _ � 1.03` � �� " 5�-{ �-{ _ FAX _
— � c.�3 `•�'�S - ��-/��a _ . . .
PERMIT TYPE
TYPE OF WORK:
�INGLE FAMILY ❑ TWO FAI�IILY
❑ NEW ,�LREPLACEIvIENT
❑ TOWNHOUSE
0 ALTERATION/REMODEL
DETAILEDDE CRIPTIONOFWORK ��0.t� � 1l,Cp� -�,rl"Lp�,�►•�, Q�,1/ZC+ Q�,IN"
�s�L1a � �- �or�Gr
FEES ARE BASED ON 510.00 PER FI��CTL'RE, EYCEPT WHERE NOTED. FUiTLRES: (Il�'DICATE TOTAL NU�IBER OF EACH BELO��
PROVIDE HEr�T LOSS CALC'S PER MAi�iU J 2�IiRAE HANDBOOK
Equipment instalied MFG: '� MODEL: S� �Y C� � SIZE/BTU �i �
MFG: 1�� MODEL: �! �� Q 7 O� -1 SIZE/BN _�I '
� A/C $25.00 ,
AIR TO AIR EXCHANGEER $15
BOILER $35.00
CHIhINEY LINER $10.00
DUCT WORK $10.00
Number of fiactures: @ $10.00 '_
Number of fixtures @ $15.00
MFG:
$1C
MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
_j_,FURNACE $35.00
_GAS DRYER $10.00
_GAS PIPING $10.00
_$
_$
SIZEBTU
_GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
_GAS iJNIT HTR $10.00
_POOL HEATER $3�.00
VENTILATOR $15.00
Number of fixtures @ $25.00 � x $25.00 = $ as= �
Number of fixtures @ $35.00 i x $35.Q0 = $ ' �� �
State Surcharge = $ 5.00
(MINIMUM FEE $40.00) Total = $ ��i �
' 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 applic on for a permit and work is not to start without a permit; that the work will be in accordance with the
approved pian in the case of y 1 �orj�'jvhich requi�s revie� and apgroval of„plans.
SIGNATURE OF APPLICANT
APPROVAL INSPECTORS SI�3`NATURE
` PLEASE NOTE: SEPARATE 1
DATE ��
L City of Fridley
, Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
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