P - 44832V � UV
Building l�ECHANICA� PermitNo.:
Inspections 1�ESIDENTIAL APPL�CATION Recei�ect By: /
763-572-3604 CITY OF FRIDLEY ��� 9
763-502-4977 FAX EFFEC�vE i-i-�o� i
DATE � YOUR E-MAIL ADDRESS
�"1 �
SITE ADDRESS
THIS APPLICANT IS: Q OWNER �CONT TOR
PROPERTY NAME: "
OENANT f+DDRESS: `�� � CI � STA'I'$ II��
PHONE: + -�.
CONTRp,CTOR co�ArrYrr.a�: CENTEBPOINT _ENERGY
SUBIvIIT A COPY OF corrTACT PExsorr: JOANN ZINKEN
YOUR STATE sTA� LicErrsE # BOND #22013346 EXp DATE 08/20/2011
LICENSE WITH �Dx�ss: 9320 EVERGREEN BLVD SUITE' B ciTY COON RAPIDS sra�IN z�55433
APPLICATION pHONE 763-757-6202 F,s,X 763-757-6701
PERMIT TYPE ��GLE FAMILY ❑ TWO FAIvIILY ❑ TOR^.JHOUSE
TYPE OF WORi{: � �W '��PLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �
FEES ARE BASED ON 510.00 P�R FIXTURE, EYCEPT WHERE NOTED. FIXTL'RES: (Ir�ICATE TOTAL NU;VIBER OF EACH BELOW) -
PROVIDE HEAT LOSS CAI.C'S PER M?urUAL J 2006 ASHRAE HANABOOK
Equipment Installed MFG: MODEL: SIZE/BN -
MFG: (�sc�� MOD£L t V � SIZEBTU����
MFG: MODEL: SIZEIBTU
A/C $3�.00 _FIREPLACE (GAS) 51�.00 _GAS RANGE/OVEN $10.00
_AIRTO AIREXCHANGEER$IS FIREPLACY�R�1 D� $35.00 NEW GAS GRILL $10.06
_BOILER $3�.00 �FURNAC �5.00 _GAS UNIT HTIZ $10.00
_CHIhfNEY LIlVER 510.00 �GAS DR 0.00 POOL HEATER 535.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTII.ATOR � 13.00
Number of fixtures' @ $14.00 'x $10.00 = $ , '
Number of fixtures @ $15.00 x $15.00 = $
Number of fixtures @$25.00 x$25.00 = S
Number of fixtures Q$35.OQ � x$35.00 =��
State Surcharge = ' $ 5.00
MINIMtiM FEE $40.00 ' Tota1='$ ` � ��
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 permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the c 11 work which e ires review and approval of plans.
SIGNATURE OF APPLICA PRINT NAME DATE '
APPROVAL INSPECTORS SI TURE DATE
PLEASE NOTE:. SEPARATE' PE RE D FORBUILDING ELEGTRI A CHA1r1ICAL WORK
City of Fridley
, Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977