P - 39842Building 1����I�l��C�.I� ����t�vo.� �� I . �
:, ,
Inspect�ons R�SID�NiIAI� APPI,ICA�'IOl� xe�e��edsy:�'�:'��� .
763-572-3604 CITY O�' �RIDLEY ��It-�c��� � � �
763-502-4977 FAX
EFFECTIVE 1-1-201I
DATE —1 '� � XOL'R E-MAIL ADDRESS
SITE ADDRESS '1 U �S � �
THIS APPLICANT IS: ❑ O�VNER I�CONTRACTOR
PROPERTY NAME: r
OWNER/ ADD�SS: {� ' S �E ci� � ST.a�lY1N zrn 5543�
TENANT p�ONE: ��/ •S�N • d �I
CONTRACTOR coNrr.arrYrraME:_ _ CENTERP�INT ENERGY
susMIT A coPY o� coNTacT PExsoN: JOANN ZINKEN
YOUR STATE sTarE LzcErrsE# BOND �22013346 EXP DATE �8�2��2�1�.
LzcErrsE vv�Tx aDD�ss: 9320 EVERGREEN BLVD SUITE B ciTY COON RAPIDS sTA�MN zu�55433
aPPL1cA�orr PxoNE .�.�757-6202 FA� 763-757-6701
PERVIIT TYPE �SNGLE FAI�IILY ❑ TWO FAivIILY ❑ TOWNHOUSE
TYPE OF WORI�: ��W ��PLACEMENT f7 ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK �_�.± �-1 l l k. �.i r
��� ����r
FEES ARE BASED ON �10.00 PER FLYTL�RE, EYCEPT WHERE NOTED. FIXTL�RES: (In�DICATE TOTAL NUVIBER OF EACA BELON}
PROVIDE HEAT LOSS CALC'S PER D'I�vUA J 2006 ASfIR:1E FIANABOOK ¢
Equipment Installed MFG: ���-- "�r �,��' MODEL: �O 0 6' ��{ SIZEBN U��
IvIFG: 1r' 1'e1r" MODEL: e� L{ pN�p3U SIZEBN IZ � ToM')
MFG: MODEL: SIZEBTU
� AIC $25.00 FIREPLACE (GAS) $I5.00 ,GAS RANGE/OVEN $lO.QQ
_AIR TO AIR E;{CHr1NGEER $15 _FIREPLACE (WOOD) $35.00 `NEW GAS GRILL $10.00
_BOILER $3�.00 1 FUI2NACE $35.00 ^GAS UN1T HTR $10.00
_CHIhINEY LINER 510.00 GAS DRYER $]0.00 POOL HEATER $35.00
DUCT WORK $] 0.00 GAS PIPING $10.00 �VENTIL.4TOR $15.00
Number of fi�ctures @ $10.00 x $10.00 = $
Number of fix:ures @ $15.00 : x $15.00 = $
Number of fixtures @ $25.00 t x $25.00 = $ ��. �V
Number of fixtures @ $35.00 � x $35.00 = $ �� !�
State Surcharge = $ 5.00
MINIMUM 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 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 appli ion for a permit and work is o start without a permit; that the work will be in accordance with the
approved plan in the case of 1 or which requires r' w nd proval of plans.
SIGNATURE OF APPLICANT PR1NT NAME J ANN Z I N I'�E DA ���/�j
.4PPROVAL INSPECTORS SI ATURE DATE
' PLEASENOTE: SEP RATE PERMITS RED FOR BU DING, ELEC'I'RICA AND E ANICAL WORK
- ty of Fridley
, Bu' din spections Department
6431 Unrversity Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977