P - 50472Building BUILDING Permit No. � I�- ��` �i
Inspections COMMERCIAL/INDUSTRIAL Received By:
763-572-3604 ' CITY OF FRIDLEY Date xec'ct:�—�°�`�
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE G��%. I 9. / Z- YOUR E-MAIL ADDRESS
SITE ADDRESS .� ��1''/ 3 r QC �� /1��' �'r, "�l L e-�
TENANT Suite No.
PROPERTY OWNER NAME: /�� L�' � ��, CidS
ADDRESS: ��� d �X PlG >�'r^ /.31 rd CI� Ct'�v�S �'A��IP ,Sy 2 6
PxorrE: `�.�'Z - 9 3��-�t�,� 2 `�
ARCHITECT NAME:
ADDRESS: CITY STATE ZII'
CONTRACTOR NAME: E e /"J � G"S'
LICEN E REQ RED ADDRESS: b�b � XG � S� d✓' �j L I/U CIT�I�• �O ���S �E/���LIP ��� z�
COM1v1ERCIAL, PHO�:��"� —�'�T�-- 6� 2�' FAX
INDUSTRIAL AND
MULTI FANIILY
PROPERTY TYPE ❑ TOWNHOUSE COMI��RCIAL/INDUSTRIAL ❑ INSTITUTIONAL
❑ MULTI-FAMILY
PERMIT TYPE ❑ ADDITION ❑ NEW CONSTRUCTION OTI�R
❑ REMODEL ❑ ROOF � SWIlvIl��IING POOL
PLEASE SUBMIT: 1. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTROTTIC
2. SURVEY/SITE PLAN LICENSE APPLICATION PLAN
3. LANDSCAPE PLANS 6. SPECIAL INSPECTION SCHEDULE
4. ENERGY CALCS 7. PERFORMANCE BOND AMOLJNT $
BUILDING TO BE USED AS: �/��i�Y� ert ` S OFFICE SF WHS sF OTT�R sF
TOTAL SIZE: � STORIES FIRE PROTECTION (Y/N) AC(Y/I�
DETAILED DESCRIPTION OF WORK /'P t� LtLG e vn e_�� ✓� �O i✓ 5 �C� c:-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 which requires review and approval of plans.
SIGNATURE OF APPLICANT :�� � J-�`-f'��1�% PRINT NAME: v� s/ L� Y ��T�se�h��: o�. � 9. � 2
APPROVAL INSPECTOR SIGNATURE: DATE: ���
AL FEES ARE BA ED ON VALUATION
--�-- � —•�-�---.--_ "'
Jl.j. 1�. n�v �.wv oy. . ........�,.,..
Sq. ft. x$ Cost/sy. ft. = Valuation $
Sq. ft. x$ Cosdsq. ft. = Valuation $
TOTAL JOB VALUATION: $ /!�, /� /�. �' � USE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
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
$ $2365 per SAC Unit (Plans to �CC for determination)
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ . n Make checks payable to: City of Fridley Attach