P - 59364Building BUILDING Permit No.. �
Inspections COMMERCIAL/INDUSTRIAL Received By:
763-572-3604 CITY OF FRIDLEY ��°,�: �' " 2
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE ��'i Z 7. � Z- YOUR E-MAIL ADDRESS
SITE ADDRESS J 2 � / � �' d � L' � Nc �r �� � � � y ���
TENANT Suite No.
PROPERTY OWNER NAME: /�% L L Yi �� �1 O S
ADDRESS: ��b d X L� L Si oj^ /�LYQ�ITT'-� �Uu� �S �i �i4�l7� ZIP S�y 2-Ei
PHONE: �%J Z -- � �O — �.�2 �
ARCHITECT NAME:
ADDRESS: CITY STATE ZIP
CONTRACTOR NAME: �L' � � !�1 � � A 4S
* NOTE: CITY �
LICENSE REQUIRED ADDRESS: ��60 ExG eL��p �- �L �d CIT�.. ��� S/5'� ZIP S�G/ Z
COMMERCIAL, pxol•rE: 93' 2- 9.��- �'.3 z 9 FAX
INDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE ❑ TOWNHOUSE CONIlvIERCIAL/INDUSTRIAL ❑ INSTITUTIONAL
❑ MULTI-FAMILY
PERNIIT TYPE ❑ ADDITION ❑ NEW CONSTRUCTION �i OTf-�R
❑ REMODEL ❑ ROOF � SWIMIvIING POOL
PLEASE SUBMIT: 1. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTROrTIC
2. SURVEY/SITE PLAN LICENSE APPLICATION PLAN
3. LANDSCAPE PLANS 6. SPECIAL INSPECTION SCHEDULE
4. ENERGY CALCS 7. PERFORMANCE BOND AMOUNT $
BUILDING TO BE USED AS:�-/'�� �%1� OFFICE sF WHS sF OTI�R sf
TOTAL SIZE: � STORIES FIRE PROTECTION (Y/N) AC(Y/1�
DETAILED DESCRIPTION OF WORK �'�°�LaGvr+ �� "'� �� �� .��% C� v h��
--.
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 uires r view and approval of plans.
SIGNATURE OF APPLICANT :!/a�! h6J� P NAME: �A S�e" ��/ ��rdS��i`E: O y Z 7� Z
APPROVAL INSPECTOR SIGNATURE: Dp`TE� �27^ /
A EES ARE BASED ON VALUATION
Sq. ft. $� Cost/sq. ft. = Valuation $
Sq. ft. x� c:osvsq. n. = v atuauon a
Sq. ft. x$ Cosbsq. ft. = Valuation $
TOTAL JOB VALUATION: $ /,�jOD °° USE OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
$ � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ !'a .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �� Make checks payable to: City of Fridley Attach