P - 35587Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
COMMERCIAL/INDUSTRIAL
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
DATE M� Z�% �'f� _ YOUR E-MAIL ADDRESS
SITE ADDRESS � % d � � %� �'!'E'.
TENANT Suite No.
PROPERTY OWNER NAME: /�%j�'y� 5 ��%i�
ADDRESS:
PHONE:
ARCHITECT I NAME:
CONTR.ACTOR
* NOTE: CITY
LICENSE REQUIRED
COMMERCIAL,
[NDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE
TYPE
PLEASE SUBMIT:
ADDRESS:
Permit No.:� � � ����
Received By:
Date Rec' d: �
CITY STATE_ZIP
CITY STATE ZIP
NAME: (,✓�1���. F3 ,�X� �-'��
ADDRESS: ('v`�7�1C� ,�a��;e.L�c.��•�e'i;, CITY� STATE�ZIP ��f2�
PHONE: 7��j '�7/.� `IZ� FAX
❑ TOWNHOUSE •�'COMMERCIAL/INDUSTRIAL ❑ INSTITUTIONAL
❑ MULTI-FAMILY
❑ ADDiTION ❑ NEW CONSTRUCTION ❑ OTHER
.0'�MODEL ❑ROOF ❑ SWIMMING POOL
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 SCHEDULE
4. ENERGY CALCS 7. PERFORMANCE BOND AMOUNT $
BUILDING TO BE USED AS: OFFICE sF WHS sF OTHER sF
TOTAL SIZE: STORIES FIRE PROTECTION (Y/N) AC(Y/N)
DETAILED DESCRIPTION OF WORK -P�eZ � tr,�, 5
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 ofplans.
SIGNATURE OF APPLICANT :��i� �� PRINT NAME: V"+e��`!= l�'Q�k� DATE: 7'-Z %"� lI
APPROVAL
SIGNATURE: DATE:
FEES ARE BASED ON VALUATION
Sq. ft. x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Vatuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
TOTAL JOB VALUATION: $ 2%?7�� USE OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
�t �%�`�
.� -
�
.
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 payable to: City of Fridley Attach
TYPE