P - 59360Building
Inspections
763-572-3604
763-502-4977 F
DATE�
SITE ADDRESS
TENANT
PROPERTY OWNER
ARCHITECT
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
COMNIERCIAL,
INDUSTRIAL AND
MULTI FANIILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT:
BUILDING
COMMERCIAL/INDUSTRIAL
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
ADDRESS: %f�0' L1'c_�rl� ✓�«7
PHONE: gSZ r ���^ �` ��
NAME:
ADDRESS:
N
Suite No
Permit No.: ����i
Received By:
Date Rec'd: �-/-
CITY�STA'D��LIP �'��/3 ?
CITY STATE ZIP
TAT$�_�!LIP S�y�
Pxorr�: �G 3°- %f/' l/ r l�'' ���% FAX
❑ TOWNHOUSE COMI��RCIAL/INDUSTRIAL ❑ INSTITUTIONAL
❑ MULTI-F�MILY
O ADDITION ❑ NEW CONSTRUCTION R
❑ REMODEL ❑ ROOF ❑ SWIMIvIlNG POOL
l. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTROIVIC
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:
TOTAL SIZE:
DETAILED DESCRIPTION OF WORK
OFFICE sF WHS sF OTI�R sF
STORIES�_FIRE PROTECTION (Y/N) AC(Y/N)
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 permit 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 o rk which r uires review and approval of plans.
SIGNATURE OF APPLICANT : PRINT NAME� ��/�� //-..�7fi� DAT�S� d
APPROVAL INSPECTOR SIGNATURE: DATE:
ALL FEES ARE BASED ON VALUATION
Sq. ft. x$ Cost/sq. ft. = Valuation $
3q, ft, x$ CostJsq. ft. = Valuation $
Sy, g, x$ CostJsq. ft. = Valuation $
TOTAL JOB VALUATION: $� (fZTZ> USE OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
$ (�.q.GS
$
$
$ 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
TYPE