P - 40103�uilding
Inspections
763-572-3604
763-502-4977 FAX
DATE ! l 1 � \ \ �
SITE ADDRESS' '�
THIS APPLICANT IS:
1`�I�CI��l�ICAL
�SID�NTIAL, APPI,ICA'TIOl�
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
PROPERTY NAME:
OWNER/
TENANT ADDRESS:
PHONE�
YOUR E-NfAIL ADDRESS
°'1 i r'1C�'�;�-r,,..
Permit No.:
Received By
�' , '�i
STATE IY�%%LIP'`��_�.
CONTRACTOR co�Arr�NA�:�ENTERPOINT ENERGY
sUS�T A coPY oF corrTncT PExsorr: JOANN ZINKEN
YOUR STATE sTa� r.icErrsE # BUND #22013346 EXP DATE OH�ZO�ZOI.1
LzcENSE wlTx ADD�ss: 9320 EVERGREEN BLVD SUITE B ciTY COON RAPIDS sTaTEMN zrr55433
�PLicaTiorr PxoNE 763-757-6202 FAx 763-757-67Q1
PERNIIT TYPE I��GLE FAIvIILY ❑ TWO FAi�fILY
TYPE OF WORI�: � ��' �-�PLACEM�NT
AILED DESCRIPT�ON OF WORK
:� ti -
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
��
FEES ARE BASED ON �1Q.00 PER FLYTL�RE, E�CEPT WHERE NOTED. FIXTtiRES: (InDICATE TOTAL NiJI�IBER OF EACH BELON)
PROVIDE HEAT LOSS C.AI.C'S PER M�INUAL J 2006 ASI�IRAE fL�.NDBOOK
Equipment Installed MFG: __ MODEL: SIZEBTU
MFG:
MODE,L:
MFG: IvIODEL:
_A/C $2�.00 _FIREPLACE (GAS) $15.00
AIR TO AIR EYCHANGEER $15 FIREPLACE (WOOD) $35.00
_BOILER $35.00 _F11.R1C�ACE $3>.00
_CHIhINEY LINER �10.00 �U`AS DRYER $10.00
_DUCT WORK $10.00 _ GAS PIPING $10.00
Number of fixtures' �a $10.00 � x $10.00 = $ t' � . C�.3
Number of fix.ures @ $15.00 x $15.00 = $
Number of fixtures @ $25.00 x $25.00 = $
Number of fixtures @$35.00 x$35.00 =$ 1�
----,-- � lt
StateSurcharge= $ 5.00 `.._...�(1
\.I
(MINIMUM FE $40.00) ota1= $
SIZE/BTU
SIZEBN
GAS RANGE/OVEN $10.00
NEW GAS GRILL $10.00
GAS LTNIT HTR $10.00
POOL HEATER $35.00
VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buildin� 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 appli 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 of 11 wor ich re uire� iew and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME JOANN ZI NKE ATE �/3l /� (
APPROVAL INSPECTORS S ATURE DATE
' PLEASE NOTE:' SEPARA ' I ARE REQUI FOR BUILDING; ELEC CAL MECHANICAL WORK
City of Fridley
�' Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977
'� �