P - 42149Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
COMMERCIAL/INDUSTRIAL
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE `y' �Z..'�I '— �l YOUR E-MAIL ADDRESS
S[TE ADDRESS S'�cG' S—� Jy` L! � /�l ����)
TENANT_
PROPERTY OWNER NAME:
ADDRESS:
PHONE:
ARCHITECT NAME:
ADDRESS:
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
COMMERCIAL,
INDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT:
NAME:
'1�,r�
7�i�'
Suite No.
Permit No.: ;� �3
Received By:
Date Rec'd: � �� �
CITY STATE_ZIP_
CITY STATE ZIP.
ADDRESS: ���r/r Lr.��ol.�cs.� «.�. .-� CITY /'�j�,,. STATE�ZIP S!�' 28`
PHONE: 7�i '� 7�7 �'2r��' FAX
❑ TOWNHOUSE �-COMMERCIAL/1NDUSTRIAL ❑ INSTITUTIONAL
❑ MULTI-FAMILY
❑ ADDITION ❑ NEW CONSTRUCT[ON �=OTHER � �''�
.�MODEL ❑ ROOF ❑ SWIMMING POOL
l. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTRONIC
2. SURVEY/SITE PLAN LICENSE APPL[CATION PLAN
3. LANDSCAPE PLANS 6. SPECIAL INSPECTION SCHEDULE
4. ENERGY CALCS 7. PERFORMANCE BOND AMOUNT $
BUILDING TO BE USED AS: OFFICE sF WHS sF OTHER sF
TOTAL SIZE: STORIES F1RE PROTECTION (Y/N) AC(YM)
DETAILED DESCRIPTION OF WORK
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 will be in accordance with the
approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT :��-- ��— PR1NT NAME: ��'Yj� � 7`%� - DATE: �J"'t 7� L1
APPROVAL INSPECTOR SIG
ALL FEES ARE BASED ON VALUATION
Sq. ft. x$ Cost/sq. ft. = Valuation $.
Sq. ft. x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cosdsq. ft. = Valuation $
fOTAL JOB VALUATION•�� ?� i�!'L USE OCCUPANCY
'ermit Fee
'lan Review
; ire Surcharge
Surcharge
iAC Charge
�rosion Control
'ark Fee
ipecial Assessments
Cotal Due
�aL -
�����
����� �
0
����lT4.
DA
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 navable to: Citv of Fridlev Attach
TYPE