P - 42113Building
Inspections
763-572-3604
763-502-4977 FAX
DATE --� � 1
SITE ADDRESS �
TENANT_
BUILDING
COMMERCIAL/INDUSTRIAL
CITY OF FRIDLEY
EFFECTIVE 1-t-20ll
PROPERTY OWNER NAME: /� v�v-I-�
ARCHtTECT
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
COMMERCIAL,
INDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT
YOUR E-MAIL ADDRESS
���-�►� �`7�
Suite No.
ADDRESS: CITY
PHONE: 3 °' 7���� I'
ADDRESS:
CITY
Permit No.: r�� � ���� '
Received B : �`
���1e R�6� � . , �;
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r
3TATE_ZIP
ATE ZIP
NAME:,�}- F'�C c) D h(�5 o n (/n/ ''� � t� F' • R� C_.o �l �i �J Cri �1 a
ADDRESS: J��� �TMi-IGf r� CITY %� iSTATF�ZIP
PHONE: / �p� = 7�(� �°C � FAX
❑ TOWNHOUSE �CC
L7IVIULTI-FAMILY
� ADDITION ❑
❑ REMODEL '�:
1. 4 SET SETS OF DRAWINGS
2. SURVEY/SITE PLAN
3. LANDSCAPE PLANS
4. ENERGY CALCS
[AL/INDUSTRIAL ❑ INSTITUTIONAL
3W CONSTRUCTION ❑ OTHER
�OF ❑ SWIMMING POOL
5. NTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTRONIC
LICENSE APPL[CATION PLAN
6. SPECIAL INSPECTION SCHEDULE
7. PERFORMANCE BOND AMOUNT $
BUILDING TO BE USED AS: OFFICE sF WHS sF OTHER se
TOTAL SIZE: STORIES FIRE PROTECTION (Y/N) AC(YM�--�y
DETAILED DESCRIPTION OF WORK /'��C �w/�T,Rd O��f -��/l'f' ��` %�n �C" 1S�.as�—
THTS 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 rmit rk 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 wo hi res review and approval of plans.
SIGNATURE OF APPLICANT • � PRiNT NAME:�� /'1 � fl►'� DATE: ���
APPROVAL INSPECTOR SIGNAE
ALL FEES ARE BASED ON VALUATION
Sq. ft. x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq, ft. = Valuation $
Sq. ft. x$ Cosdsq. ft. = Valuation $
TOTAL JOB VALUATION: $��E{6�� Ob USE OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
DATE:
$ �'j'"�� 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 determinatian)
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � �� Make checks payable to: City of Fridley Attach
TYPE