P - 41742Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
C OMMERCIAL/INDU STRIAL
CITY OF FRIDLEY
]-1-2011
PermitNo.: �+�1� ��-��
Received By: .,�V �
Date Rec' d: � � .3"
DATB ��' ���^� '� �� �7 / I YOUR E-MAIL ADDRESS / ��/��-� � %- �% C �) � / �,=� - �° �"�/
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SITE ADDRESS S�'�,� �lI � �T���ti S�' ���r���`-f /�'12.�' "
TENANT_
Suite No.
PROPBRTY OWNER NAME: ���� �% /f�S a✓1 S�'�''� �'1 C` �.
__ — — _
ADDRESS: S � � � (� � ��Y� �� ��ITY�� Y`/����� STATE✓��IP J �S y � 1
PHONE: ��3 i ��t�� a'� � �' l �j � "� ( � �t � G d ,C-�
ARCHITECT NAME:
ADDRESS: CITY STATE ZIP
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
COMMERCIAL,
INDUSTRIAL AND
MULTl FAMILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT:
ADDRESS: .� �/�� IL�')�
PHONE: � I�- � � � - j CU �]
� ( 5 � �--i-C�
�. CITY 13C,e�✓, II� STATE�ZIP �� 3��
FAX
❑ T HOUSE ❑ COMMERCIAL/iNDUSTRIAL ❑ INSTITUTIONAL
ULTI-FAMILY
ADDITION ❑ NEW CONSTRUCTION OTHER
❑ REMODEL ❑ ROOF ❑ SWIMM[NG POOL
l. 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: OFFICE sF WHS sF OTHER�_sF
TOTAL SIZE: STORIES FIRE PROTECTION (Y/N) AC(Y/N)
, --r- ; .,
DETAILED DESCRIPTION OF WORK � � � I�+. �' i �? � �'� > 7 f '' � : ����`��,a ,. � _���,;" °�;��� j� e I-'tf ��Yl-�' -s _
THIS 1S AN APPLICATION FOR A PERMIT-NOT VAL(D UNTIL PROCESSED
1 hereby app(y 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 wil( be in accordance with the
approved plan in the case of all work wh�h requires�ew and approval of plans.
SIGNATURE OF APPLICANT : ���� � � �
APPROVAL INSPECTOR SIGNATURE: _,
A
NA� "pt"T� � { �( II�LS�� DATE:
ON VALUATION
Sq. ft. x$ ( Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
TOTAL JOB VALUATION: $ �� . 4+� USE OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
$ 5 �.�5"
$
$ /
$ .
$
$
$
$
$ C'�i � ;�i �
DA
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 pavable to: City of Fridley Attach
TYPE