P - 48171Building
Inspections
763-572-3604
763-502-4977 FAX
DATE J�
SITE ADDRESS
TENANT
PROPERTY OWNER
ARCHITECT
CONTRACTOR
* NOTE: CITY
LICENSE REQUIlZED
COMIv�RCIAL,
INDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE
PERNIIT TYPE
BUILDING
Permit No.: ����d��
COMMERCIAL/INDUSTRIAL Received By:
CITY OF FRIDLEY Date Rec'd: � t
EFFECTIVE ]-1-2012
2o I Z- YOUR E-MAIL ADDRESS S�� •�+'R-� �� B" t�.rj $y l�
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Suite Na
NAME: �-��� G�o �I-�-►�I
ADDRESS: CITY STATE ZIP
PHONE• �4_r IZ 1 Zo3 • o'� `� (
NAME:
ADDRESS: CITY STATE ZIl'
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ADDRESS: � I So Srr- cd�r�t � �t9. CITY �� b�wl�� STATE Kw ZIP � Z-
PHONE: Z 3 7�-3� � FAX
❑ TOWNHOUSE OMMERCIAL/1NDUSTRIAL ❑ INSTITUTIONAL
� MULTI-F�MILY
❑ ADDITION � NEW CONSTRUCTION Tf�R
❑ REMODEL ❑ ROOF SWI1vIIv1ING P(
PLEASE SUBMIT: 1. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTROrTIC
2. SURVEY/SITE PLAN LICENSE APPLICATION PLAN
3. LANDSCAPE PLANS 6. SPECIAL INSPECTION SCHEDULE
4. ENERGY CALCS 7. PERFORMANCE BOND AMOUNT $
BUII.DING TO BE USED AS: OFFICE sF WHS sF OTI�R sF
TOTAL SIZE: STORIES Z FIRE PROTECTION (Y/I� AC(Y/I�
DETAILED DESCRIPTION OF WORK ���.� s wt ..+��{� �+.L 1�,?(..� E+.z� �.,-• •��� Q
� /�s,� � .iQ �� ��
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 anly an application for a pe it and work ' 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 vXh�ch requires vibw and approval of plans.
SIGNATURE OF
AL 1NSPECTOR SIGNATURE:
/���JI
'I-��_n1 Gi?��L�O1J DATE: I' I�•�( Z
PRINT NAME: .Si�'�
DATE:
ON VALUATION
Sq, 8, x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
TOTAL JOB VALUATION: $ I o, �- S o USE OCCUPANCY TYPE
Permit Fee
Pian 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
$ �j .0005 x Permit Valuation Minimum $.50
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$�T, "�j � Make checks payable to: City of Fridley Attach
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