P - 46265Building
Inspections
763-572-3604
763-502-4977 FA�
DATE � � �j � l
SITE ADDRESS ^�_
THIS APPLICANT IS:
l��I���ANIC�.L
RESIDEN'I'IAL .�PPLICA'I'ION
,
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
PROPERTY NAME:
OWNER/ �Dx�ss:
TENANT ^
YOUR E-MAIL ADDRESS
�CONTRACTOR
.�- .
�• «�
Permit No.:
Received By:_
D��c'��N
CONTRACTOR cor�tPAxYU�: CENTERPOINT ENERGY
SUB1vIIT A COPY OF cor�TACT PExsoN: JOANN Z I NKEN
YOUR STATE STATE LICENSE # Bd�� #ZZO133A�6 EXP DATE �8I2O%ZO11
L�cENS� wrrx ,�D�ss: 9320 EVERGREEN BLVD SUITE' B crrY COON RAPIDS srA�MN z�55433
APPLICATION pHONE 763-757-6202 F� 763-757-6701
PERMIT TYPE ��GLE FAMILY ❑ TWO FAiviTi.Y
TYPE OF WORI{: � �W `�REPLACEMENT
O TOWNHOUSE
❑ ALTERATION/REMODEL
i� � � • • � • � a. ����� . . _ . � � _ � . � r
� .��*� � . � �
FEES ARE BASED ON S1U.00 PER FLYTLTtE, EYCEPT WHERE I�OTED. FI?iTL"RES: (IlV�ICATE TOTAL NUrIBER OF EACH BELO`V)
PROVIDE HEaT LOSS C.4LC'S PER M.�vUAL J 2006 ASHR?.E I-LaNDBOOK. ./
EquipmentInstalled MFG: �L�,�„l� MODEL: �j�i,• d� SIZEBT[J� ti�8{ �.(
NffG:- ��� MODEL: ��1`1�..• 6'a,�-t s�z�a�ru �'Ov� 13S r
MFG:
C $25.00
AIR TO AIIi EXCHANGEER $15
BQILER $3�.00
CHI1vINEY L1NER $10.00
DUCT WORK $10.00
Number offixtures' @ � 10.00 z $1
Numbcr of fixtures @ $15.00 x $1
N���� b f fi �� 2 00 ��� 2
MODEL:
FIREPLACE (GAS) $15.00
FIREPLACE (WOOD) $35.00
�L3KNACE $35.00
GAS DRYER $10.00
GAS PIPING $10.00
_$
_$
.� -�� rV1
SIZE/BTU
_GAS RANGFJOVE.N $10.00
�NFW GAS GRILL S 10.00
GAS UNIT HT'R $ ] 0.00
�POOL HEATER $35.00
VENTILATOR $15.0�
um er o xtures @ $ 5. x $ .,..,� — ,, �-- ---
Number of fixtures @ $35.00 � x $35.00 = $ �J� ���
Stafe Surcharge = ' $ 5.00
MINIMUM FEE $40.00 Tota1= $ �� ' ��
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID Li23TIL 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 Pridley 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 plan in the case of Y� ich req 'res r view • d approval of plans.
SIGNATURE OF APPLICANT ' � NAME J A C DATE �3 �
.....�..... . �,.._....,........ ...,. �....... � /% ,t �.n ,. . T.. � � �
PLEASE NOTE: SEPARA
City of Fridley �
, Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977