P - 48041Buildin�
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
COMMERCIAL/INDUSTRIAL
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
Permit No.:�� i �� . �
Received By: "
�[��� �_�1L
DATE�� `;�d �( YOUR E-MAIL ADDRESS 1 ti�.ua`�� C���•'� �����'"
S�TEADDRESS. J�c��`j, 3r� (i}�� lV`��� �
TENANT_ /� � ii �t L( va �,O( S, l Suite No.
PROPERTY OWNER NAME: I� (� 2sS f0✓'G�.� �- � s
ARCHITECT
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
COMMERCIAL,
INDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT:
ADDRESS:_PU �D� ���?S�j� CITY SL�
PHONE: �'�',��— �i�L�
NAME:
ADDRESS:
STATF�LIP �����o
CITY STATE ZIP
NAME: � �i,� �c�c;� CVCJ�n s�..vc;t-C U� - _ _
ADDRESS: �-�"'t 2 Z. C��A(<<-�11ti �� �v Z CITY ��L- STATFL�i,�ZIP ��`E O%
PHONE: ivl2 �522 -(�Z�, FAX �C Z �Z2 ���-��J
TOWNHOUSE ❑ COMMERCIAL/INDUSTRIAL ❑ INSTITUTIONAL
MULTI-FAMILY
❑ ADDITION ❑ NEW CONSTRUCTION ❑ OTHER
❑ REMODEL I�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: �+�� �� p(., OFFICE sF WHS sf OTHER � sF
TOTAL SIZE: �j 2 W�� STORIES ,;� FIRE PROTECTION (Y/N) AC(Y/N)�
DETAILED DESCRIPTION OF WORK P+�a�2 �v4w,�s+� c��'wF�S. y S�c;�� F✓;�� r�} � G��„
i� � �- t � �, �'�r�wk.� �-� ✓�
THIS [S 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 : � PRINT NAME:� �je�� �.,U ��J �'�(� DATE: O� �F p�QL
APPROVAL INSPECTOR SI(
TURE:
AI_I, FF.F.S ARF. RA�ED ON VALUATION
Sq. ft. x $
Sq. ft. x $
Sq. ft. x $
COTAL JOB VALUATION: $
'ermit Fee
'lan Review
� ire Surcharge
Surcharge
iAC Charge
3rosion Control
'ark Fee
>pecial Assessments
fotal Due _
$ ��1'l.c�I:�
$
$ r7
$ f ��
$
$
$
$
$ I (r ` , 1
DATE:
Cost/sq. ft. = Valuation $ ���—
Cost/sq. ft. = Valuation $
Cost/sq. ft. = Valuation $
USE OCCUPANCY TYPE
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 Sti