P - 48630Building BUILDING Permit No.��?/ , `� �
Inspections COMMERCIAL/INDUSTRIAL Received By•
763-572-3604 CITY OF FRIDLEY nate xec'd: � r2—
763-502-4977 FAX EFFECTiVE 1-1-2012
DATE -- � YOUR E-MAIL ADDRESS � t�J' J� I'L' �01 ���'tl (L Ce M
SITE ADDRESS
TENANT Suite No.
PROPERTY OWNER NAME: �
ADDRESS: CITY STATE_ZIP
PHONE:
ARCHITECT NAME: � il/' /'* -
ADDRESS: CITY STAT'E ZIP
CONTRACTOR NAME: � t �
* NOTE: CITY
LICENSE REQUIRED ADDRESS: � CITY �j �4 STATE�ZIP ���
COIvIlv1ERCIAL, pHONE: � (�1- �Ll�ai 37� FAX
INDUSTRIAL AND
MULTI FANIILY
PROPERTY TYPE ❑ OUSE ❑ CONIMERCIAL/INDUSTRIAL ❑ INSTITUTIONAL
MULTI-FAMILY
PERMIT TYPE ❑ ADDITION ❑ NEW CONSTRUCTION 'TI�R �b/'
❑ REMODEL ❑ ROOF ❑ SWIlvIlvIING POOL
PLEASE SUBMIT: 1. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTROrtIC
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 OTI�R � sF
TOTAL SIZE: a STORIES FIRE PROTE� TION (Y/N) AC(Y/I�
DETAILED DESCRII'TION OF WORK �i��0� DAT/` �� �Gr� 1"'�'.n �`��OA-�
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 of all work which requires review and approval of plans.
�,, �.d'
SIGNATURE OF APPLICANT : T^�� Irt%/'/ .Afsl .4St�YF PRINT NAME: �/�,N W r�I � DATE: �Q3,��
APPROVAL INSPECTOR SIGNATURE: DATE:
ALL FEES ARE BASED ON VALUATION
Sq, ft, x$ CostJsq. ft. = Valuation $
Sq. ft. x$ Costlsq. ft. = Valuation $
Sq. {�. os�ft. = Valuation $
TOTAL JOB VALUATION: $� � C�' — USE OCCUPANCY.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
$
$
$
$
$
$
$
$ ,`y,
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 payabte to: City of Fridley Attach
TYPE