P - 48154Building
Inspec�ions
763-572-3604
763-502-4977 FAX
DATE \ 01- ��j�' � ��
SITE ADDRESS LJ � �.C�
TENANT
PROPERTY OWNER
BUILDING
COMMERCIAL/INDUSTRIAL
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
�� S�'t . `N � .
Suite No.
Permit No.: U ��
Received By:
Da��'��� � � ����
NAME: ��C,�w� �� . � -�y
ADDRESS: `�`�1 a. C) �� ��' CITY �r � C��� STATEMII�IP .
PHONE: 1�o �- Z 3�- l0'31 C�
ARCHITECT I NAME:
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
COMMERCIAL,
INDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT:
ADDRESS:
CITY STATE ZIP
NAME: C �N .L CO r�S�.LL--t-� � ,r1
ADDRESS: �'-�5 (oC`��I �J��. Lc�2 �� CITY�,\'fiC2�'�'► STAT�ii)�• Z1P_ t�,3`� l
PHONE: `-1 lo� ^ Z �s lo - ��.� FAX 'i "�-�=.?j �c1 "�' � 0���
❑ TOWNHOUSE ❑ COMMERCIAL/INDUSTRIAL ❑ INSTITUTIONAL
0'MULTI-FAMILY
❑ ADDITION ❑ NEW CONSTRUCTION �}OTHER 5 � `�'�-�
❑ REMODEL ❑ ROOF � SWIMMING POOL
T. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTRONIC
2. SURVEY/S1TE PLAN LICENSE APPLICAT[ON 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: u S m�r S �cD � r� STORIES FIRE PROTECTION (Y/N) AC(Y/N)
DETAILED DESCRIPT OF WORK �'2 S�C�C� �. l��S� ��� ��-.
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 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 withoux •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 : LQ�,1��8� C�'� PRINT NAME: �Q�.`�� T�jp�.CSO ''i DATE: �c3+^i�' ZOI I
APPROVAL INSPECTOR SIGNATURE:
ALL FEES ARE BASED ON VALUATION
Sq. ft. x$ Cosdsq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
COTAL JOB VALUATION: $�'a � OflO ► c`� O USE
'ermit Fee
'lan Review
?ire Surcharge
Surcharge
3AC Charge
3rosion Control
?ark Fee
3pecial Assessments
Cotal Due
$
$ r
$ �
$
$
$
$
$ a; �a �
DATE:
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
lations