P - 40835Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
COMMERCIAL/INDUSTRIAL
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE ���I I YOUR E-MAIL ADDRESS
SITE ADDRESS .S�'�S 2CO�5 fN�
TENANT_ (1� 1 LT C F��S t�ne Suite No.
Permit No.:
Received By:_
D�(���9� P
�
PROPERTY OWNER NAME:�j'� \� C pml S�,✓
ADDRESS: S� 3� 3'� 5'F N� CITY �' �< STATF�►1ZIP $ 5'42 1
PHONE:
ARCHITECT NAME:
ADDRESS: CITY STATE ZIP
CONTRACTOR
'� NOTE: CITY
LICENSE REQUIRED
COMMERCIAL,
INDUSTRIAL AND
MLJLTI FAMILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT:
NAME:�C� 1�1on.0 � X�k1'.ors L.(,G
ADDRESS: ��](s(� 133"� ��✓ 4v✓ CITY po*iSTATEn..✓ZIP S")'��y_
PHON� ��� ZZI -�9�� FAX 7��"i - � �I D '�� �'/ /
❑ COMMERCIAL/1NDUSTRIAL ❑ INSTITUTIONAL
MULTI-FAMILY
❑ ADDITION ❑ NEW CONSTRUCTION ❑ OTHER
❑ REMODEL .0'ROOF ❑ SWIMMING POOL
l. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIG[TAL OR ELECTRONIC
2. SURVEY/SITE PLAN LICENSE APPLICATION PLAN
3. LANDSCAPE PLANS 6. SPECIAL INSPECTION SCHEDULE
4. ENERGY CALCS 7. PERFORMANCE BOND AMOUNT $
BUILDING T� � US�D AS: OFFICE sF WHS sF OTHER sF
TOTAL SIZE: STORIES I''y __FIRE PROTECTION (Y/N) AC(Y/N)
DETAILED D CRIPTION OF WORK �r �e —+oo..E'
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appfy for a building permit and I acknowledge that the information above is compiete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minn o 0 odes; that I understand this is not a
, permit but only an application for a permit and work is not to start without a perm �������V ill be in accordance with the
� approved plan in the case of all wo�which req�ire^eview and approval of plans.
_ ,
SIGNATURE OF APPLICANT :
APPROVAL INSPECTOR SIGNATURE:
NAME:
ALL F ARE BASED ON VALUATION
�� DATE: 'rl -
DATE: �
Sq. ft. x$ ` Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cosdsq. ft. = Valuation $
TOTAL JOB VALUATION: � USE OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Controi
Park Fee
Special Assessments
Total Due
$ II I�LS
$
$ ,
$
$
$
$
$
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
lations