P - 47275Building MECH�NICA�, Permit No.:�
Inspections RESID�NTIAL APPLICATION Received B
763-572-3604 �ITY OF FRIDLEY ����� Q
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE 1 � �S �� I YOUR E-MAIL ADDRESS
SITE ADDRESS _ ���Q Q.h r�E t/� S T �
THIS APPLICANT IS: ❑ OWNER L'}CONTRACTOR
PROPERTY NAME: � �o
OWNER/ ADDRESS:, VQ1/� �' CITY il � ��G+L. STATE i'�"LIP��'4 3,�
TENANT
PHONE: �t0 � �- a
CONTRACTOR con�Arr�NAME: CENTERPOINT ENERGY
SUBMIT A COPY OF corrracT rExsorr: JOANN ZI NKEN
YOUR STATE sTa� LicErrsE# BUND #22013346 EXP DATE �8�2��2�11
LicErrsE wrTx ADD�ss: 9320 EVERGREEN BLVD SUITE B ciTY COON RAPIDS STATEMN z�55433
APPLICATTON PHONE. '�j(�7,`']�(.(° �C.��jz% _ FAX_ �' (��'"� `t?`�. ,Ca{��j�,
PERMIT TYPE �-SItvGLE FAMILY ❑ Tw0 FAtvt��.Y ❑ TOWNHOUSE
TYPE OF WORIi: � ��' � �PLACEMENT ❑ ALTERATION/REMODEL
DETAILEDDE C PTIONOF WORK �HC�Gc..�� �►rr��er �L�r_V'�.r*C°+�' Ql.v1c� �' ,t r'
� b� �� t O+I��X' .
FEES ARE BASED ON 510.00 PER FI�YTLT2E, EYCEPT WHERE NOTED. FIkTUIZE5: (Ir�ICATE TOTAL NiTVIBER OF EACH BELO��
PROVIDE HEAT LOSS CALC'S PER bZ�uvU J 2006 ASHIt�E HANDBOOK
EquipmentInstalled MFG: �rri�EY^ MODEL: �J���%C��OC7' ��{ SIZEBTLJ �t���
IvIFG: r�ri�r MODEL: o�y RIV171 �� SIZEBN o��N (7 SL��
MFG: NIODEL: SIZEBTU
�A/C $3�.00 FIREPLACE (GAS) $1�.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 _FIREPLACE (WOOD) $3�.00 _NEW GAS GRILL $10.00
_BOILER $3�.00 �FURNACE $3�.00 GAS LJNIT HTR $10.00
CHIhINEY LINER $10.00 GAS DRYER $10.00 POOL HEATER $3�.00
DUCT WORK $10.00 GAS PIPING $10.00 V ENTILATOR $1 �.00
Number of fiactures @ $10.00 x $lO.OQ = $
Number of firtures @ $15.00 x $15.00 = $ '
Number of fixtures @ $25.00 �_ x $25.00 = $ �� +�
Number of fixrares @ $35.00 � ' x $35.00 = $ " �4 �
State Surcharge = $ ' S.00
MINIMUM FEE $40.00) Tota1= $ C.t s. �V
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID ITNTIL 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 applica ion 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 a ork ich requires re iew d approval of plans.
SIGNATUREOFAPPLICANT NAME JOANN ZINKEN DATE � w�S I/
APPROVAL INSPECTORS SIG ATURE DATE
PLEASENOTE: SEPARATE PERMITS ARE REQUIRED FOR BUILDING; ELECTRICAL AND MECHANICAL WORK
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977