P - 59372Building
Inspections
763-572-3604
763-502-4977�FAX
DATE �
SITE ADDR
TENANT_
PROPERTY OWNER
ARCHITECT
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
CONIMERCIAL,
INDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT:
BUILDING
COMMERCIAL/INDUSTRIAL
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
YOUR &MAIL ADDRESS
NAME:
PHONE:
NAME:
ADDRESS:
NAME: �
ADDRESS• S�n� �e �
PHONE: �Co�� '%,ILG '"�l' �i Y� F
n
No.
Permit No.�� � � � �
Receive B : � �
Date
�� . cl` �
STATE ZIP
CITY STAT'E ZIP
❑ COMI��RCIAL/1NDUSTRIAL
TA
❑ INSTITUTIONAL
_ �
�IIJLTI-FAMILY
❑ ADDITION ❑ NEW CONSTRUCTION S��G POOL
❑ REMODEL ❑ ROOF
1. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTROTiIC
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
TOTAL SIZE: STORIEI
DETAILED DESCRIPTION OF WORK
SF WHS SF OTHER SF
OTEC�'ION (Y/N) AC(Y/1�
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 pertnit 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 whic qu' s review and approval of pl s.
SIGNATURE OF APPLICANT RiNT NA G� 7 DATE�
i�, ., /I p�,�, nA�: g 7 1
AL
ALL FEES ARE BA�`ED ON VALUATION
Sq_ g. X$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sy. ft. = Valuation $
Sq. �, X$ Cost/sq. ft. = Valuation $
TOTAL JOB VALUATION: $�, 0��1b � USE OCCUPANCY 1'YPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
$ lP l� . L�
$
$ � < . t3
$ ( C�
$
$
$
$
$ D "� �
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 MWCC for determination)
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach