P - 41778Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �_` � I
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
1VI�C�IANICAI�
RESID�NTIAL APPLICATION
CITY OF FRIDLE�
EFFECTIVE 1-I-2011
❑ OWNER
NAME:_
ADDRESS:
YOUR E-MAIL ADDRESS
,t(� 1 e Ir � ,�j�,.S..S
l�CONTRACTOR
.� a.r e
l "�,a � �e�r' R�ss
. � ��_ �� �� �--�-,
Permit No.:
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CONTRACTOR co�rnArr� N�:_ _ CEN7ERPOI NT ENERGY
SUBMIT A COPY OF corrrACT PExsorr: JOANN ZINKEN
YOUR STATE sTA� LicExsE # BOND #22013346 �{p Dp� �8�2��2�11
LICENSE WITH ,e,DDx�ss: 9320 EVER6REEN BLVD SUITE ° B crrY COON RAPIDS sTA�MN z�55433
APPLICATION PHO� —��3 _� S- S�,EO�i FAX _
71o3-7g5- 55/OG _
PERMIT TYPE
TYPE OF WORK:
�SINGLE FAMILY ❑ TWO FANIILY
❑ NEW �tEPLACEMENT
❑ TOWNHOUSE
❑ ALTERATION/fLEMODEL
DETAIL �D DESCRIPTION OFyvO�uc ���5��`\ \ �C,�,p� �,e `�Q.r'r'i �°r � �np,�,C ,e
�, Q �� _r�v1c, i� t an�e r.
FEES ARE BASED ON $10.00 PER FIXTURE, EYCEPT WHERE NOTED. FIXTLRES: (IlV�DICATE TOTAL NUYIBER OF EACH BELO�i�
PROVIDE HEAT LOSS CALC'S PER MAi�TU J 20�HRAE HANDBOOK p p.
EquipmentInstalled MFG: MODEL: �O rn�i�d SIZE/BN ob�V�O
MFG: t.1�`r't 1P. V MODEL: a�I�,�Q �3�p SIZEBTU 7� '[Vh �$$G'
MFG: MODEL: SIZEBTU
� A/C $25.00 _FIREPLACE (GAS) $1�.00 _GASRANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW C�AS GRII.L S1Q.0�
BOILER $35.00 �FURNACE $35.00 _GAS UNIT HTR $10.00
_CHIhINEY LINER $10.00 ,GAS DRYER $10.00 _POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTII.ATOR $15.00
� ' ��'a l�
Number of fixtures @ $35.OQ x $35.00 = $ �
State Surcharge = ' $ 5.00
(MINIMUM FEE $40.00) Total = $ ��t ad
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buildin; permit and I acknowiedge that the information above is complete and accurate; that the work wiil 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 appl' tion 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 case o al wor hic eq ' s evie and approval of plans.
SIGNATUREOFAPPLfCANT , RINTNAME JOANN ZINKEN / ibATE i//��/II
APPROVAL
PLEA;
TE
City of Fridley V
, B ' ding Inspections Department
6 niversity Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977