P - 40727Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
COMMERCIAL/INDUSTRIAL
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE ��—� � YOUR E-MAIL ADDRESS
SITE ADDRESS �'3S �CO�S'i'N�
TENANT_ �1/� � �.T C F�[LLS Dr✓ Suite No.
Permit No.
Received By:_
D�(���� P
��,
PROPERTY OWNER NAME: rn'� e� C �Pml S a,.�
ADDRESS: Sa 3� 3'� S'f" /►�G CITY �' I t STATEI�IZIP S;� t./ 2 1
PHONE:
ARCHITECT NAME:
ADDRESS:
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
COMMERCIAL,
INDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT:
CITY STATE ZIP
NAME:�_�r►�t � X-�►��5 t,.LG
ADDRESS: ��] (s(,t � 3'3 �� � wr �vc/ C1TY o�i/ STATE I�. �/L1P i�"�ea y
PHON� � Z2l — �'-{� FAX %�o "� - � GI O � `�� �'I I
❑ TOWNHOUSE ❑ COMMERCIAL/INDUSTRIAL ❑ INSTITUTIONAL
�MULTI-FAMILY
❑ ADDITION ❑ NEW CONSTRUCTION ❑ OTHER
❑ REMODEL �ROOF ❑ SWIMMING POOL
1. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTRONIC
2. SURVEY/SITE PLAN LICENSE APPLICAT[ON PLAN
3. LANDSCAPE PLANS 6. SPECIAL INSPECTlON SCHEDULE
4. ENERGY CALCS 7. PERFORMANCE BOND AMOUNT $
BUILDING TO US�D AS: OFFICE sF WHS sF OTHER se
TOTAL SIZE: STORIES I' v FIRE PROTECTION (YM) AC(Y/N)
DETAILED D CRIPTION OF WORK r�r —r op,.�
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 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 application for a permit and work is not to start without a permit on site; that the work wiU be in accordance with the
approved plan in the case of all work which reqaires review and approval of plans.
SIGNATURE OF APPL[CANT :
APPROVAL
NAME: �rD`�'� lc..✓'. G��r��� l DATE: '�'T -
ALL F ARE BASED ON VALUATION
Sq. ft. x$ ` Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Va(uation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
TOTAL JOB VALUATION: � USE OCCUPANCY
7'"
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion ControF
Park Fee
Special Assessments
Total Due
$ l I I .'LS
$
$ .
$
$
$
$
$ --__
DATE:
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$2230 per SAC Unit (Plans to MWCC for determination)
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( }
Make checks aavable to: City of Fridley Attach
TYPE