P - 59363Building BUILDING Permit rio.:a6
Inspections COMMERCIAL/INDUSTRIAL Received By:
763-572-3604 CITY OF FRIDLEY vat��: 01
763-502-4977 FAX EFFECTIVE 1-1-2012
DAT'E � 4• z 7.��- YOUR E-MAIL ADDRESS
SITE ADDRESS .�� 6 � .� � � � s L' /�� �/� � �L £'- � �/�'
TENANT Suite No.
PROPERTY OWNER NAME: � �
ADDRESS: prP6D XC e L�, p r ,BL y C�' CITY.Ja c�r S A ZIP .S.S �12�
PHONE: 9J'�.2 "' C%.�l�" U� .� � %�
ARCHITECT NAME:
ADDRESS: CITY STATE ZIP
CONTRACTOR NAME: /YQG� 1� %� D S
LICEN E REQUIRED ADDRESS: 6(��� G XG � L S�4r �J�YcY CITY.S�� C�V' S S A'T� ZIP SS�/ 2
COIvIlv1ERCIAL, pHONE: 9�Z ` %�� " �� � / FAX
INDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE ❑ TOWNHOUSE COMI��RCIAL/INDUSTRIAL ❑ INSTITUTIONAL
O MULTI-FAMII.Y
PERMIT TYPE ❑ ADDITION ❑ NEW CONSTRUCTION OT'I-iER
❑ REMODEL ❑ ROOF ❑ SWIIvIl��IING POOL
PLEASE SUBMIT: 1. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTRONIC
2. SURVEY/SITE PLAN LICENSE APPLICATION PLAN
3. LANDSCAPE PLANS 6. SPECIAL INSPECTION SCHEDLJLE
4. ENERGY CALCS 7. PERFORMANCE BOND AMOUNT $
BUII.,DING TO BE USED AS: �,r�ii�i'n e►�� OFFICE sF WHS sF OTHER sF
TOTAL SIZE: � STORIES--�-- FIRE P�R�OT� CTION (Y/N) AC(Y/N)
DETAILED DESCRII'TTON OF WORK /"�-p G�. e�r �- �i v�`�"Wi �� �D ��
—�
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 w ich require review and approval of plans.
SIGNATURE OF APPLICANT : �l Z1 PRINT NAME: i�Q�� �� ii �era .�E'��b� �: �`� � 2 �' 12"
APPROVAL INSPECTOR SIGNATUR DATE: �
L FEES ARE BASED ON VALUATION
Sa. ft. Cost/sq. ft. = Valuation $
Sq. ft. x$ Cosdsq. ft. = Valuation $
Sq. ft. x$ Cosdsq. ft. = Valuation $
TOTAL JOB VALUATION: $ /,�SDO. USE OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
$ �.� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ ' .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ $2365 per SAC Unit (Plans to NIWCC for determination)
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �� .(p S Make checks p'ayable to: City of Fridley Attach
7 � 3 — �l � 3 — -7 �6 9 J 1/a f; L ► � �e �� � �c�