P - 35081Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�7 I I
SITE ADDRESS
TENANT_
PROPERTY OWNER I NAME:
� _Bi,TILDING
C O MME 1�C IAL/IND U S TRIAL
�
CITY OF FRIDLE�;w,:
EFFECTIVE 1-1-2011 "'�
YOUR E-MAIL ADDRESS �
Suite No.
ADDRESS: '����� �i,�YQ.C� �L.CI� CITY
PHONE: 6S\ ^Z�'S" � ��
ARCHITECT I NAME:
. I ADDRESS:
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
COMMERCIAL,
[NDUSTRIAL AND
MULTI FAMILY
PROPERTY TYPE
NAME: fF � L�
CITY
ADDRESS: '� i) � i�,�`�,_��� CITY
PHONE: �\Z� \^L�„��O FAX_
O TOWNHOUSE
❑ MULTI-FAMILY
IAL/INDUSTRIAL
Permit No.: ��I � '�` L�
Received By: �' Y l
D�C���d� � � 12 1
�STAT�i�YP��I�,,.��
STATE ZIP
a► �STATE M�IP � � �%
❑ INSTITUTIONAL
PERMIT TYPE ❑ ADDITION ❑ NEW CONSTRUCTION ❑ OTHER -
MODEL ❑ ROOF ❑ SWIMMING POOL
PLEASE SUBMIT: 1. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTRONIC
2. SURVEY/SITE PLAN LICENSE APPLICAT[ON PLAN
3. LANDSCAPE PLANS 6. SPECIAL INSPECTION SCHEDULE
' 4. ENERGY CALCS 7. PERFORMANCE BOND AMOUNT $
BUILDING TO BE USED AS: RtV S��l�� C.� OFFICE ��_sF WHS __�s� OTHER.
TOTAL SIZE: ���_ STORIES \ FIRE PROTECTION (Y/N)� AC(Y!
OF WORK
SF
THIS IS AN APPLICATION FOR A PERMIT-NOT VALfD UNTIL P1�0 ESSED
1 hereby apply for a building permit and t acknowledge that the information above is coria►ptete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Const�uction 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 ,�inF site; that the work will be in accordance with the
approved plan in the case of all or which req i s reyiew and approval of plans. •
SI. , ATURE OF APPLICAN . PRINT NAME: �C"A�+W4� �,�,i�� DATE: �I
�:t r;, .
A L INSPECTOR SIGNATURE: DATE:
ALL FEES A[tE BASED ON VALUATION
� Sq. ft. x$ Cost/sq. ft. = Valuation $��00�
Sq. ft. x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $ I/
JOB VALUATION: $�ObO `"' USE�� OCCUPANCY�_ TYPE 1/ '�
Perinit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Contro}
Park Fee
Special Assessments
Totai Due
•�
_►
L�� �r'
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 aavable to: Cityo uf Fridley Attach
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