P - 44451Building BUILDING
Inspections COMMERCIAL/INDUSTRIAL
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECT[VE 1-1-2010
DATE �` Z O ` r � YOUR E-MAIL ADDRESS ' j/S.� ,/t�t �
SIT'E ADDRESS ��
TENANT �„�
PROPERTY OWNER
ARCHITECT
CONTRACTOR
* NOTE: CITY
LICENSE REQUIRED
COMIv1ERCIAL,
INUUSTRIAL AND
MULTT FAMILY
PROPERTY TYPE
PERMIT TYPE
PLEASE SUBMIT:
�
Suite No.
ADDRES5: CITY
PHONE:
Permit No.: a:� � V �i � �1
a
Received By: +��'
���E � ia�-Gk/-1�-
STATE_ZIP
NAME: �J /�
ADDRESS: CITY STATE ZIP
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CITYS�o�'�J'�ATE G�ZIP SS%Z�
PHONE: � (p 3 ° Z `''J / — i 7 � � FAX
❑ TOWNHOUSE C3-edMMERCIAL/INDUSTRIAL ❑ INSTTTUTIONAL
❑ MULTI-FAMILY
�❑ A DITION ❑ NEW CONSTRUCTION ❑ OTI-�R
MODEL ❑ ROOF � SWIMMING POOL
1. 4 SET SETS OF DRAWINGS 5. CONTRACTORS OR LICENSE 8. 1 SET-DIGITAL OR ELECTROI�TIC
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: `Zf� �rC �F�
OF W ORK
OFFICE sF WHS sF OTf�R sF
STORIES / FIRE PROT'ECTION (Y/1� _ AC'��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 of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT : PRINT NAME: ✓TG/J "[.t- d� � W� DATE: 1' " ZD � 1 C7
APPROVAL INSPECTOR SIGNATURE� DATE:
ALL FEES ARE BASED ON VALUATION
Sq. ft. x$ CostJsq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
Sq. ft. x$ Cost/sq. ft. = Valuation $
TOTAL JOB VALUATION: $�('�n n� USE OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
SAC Charge
Erosion Control
Park Fee
Special Assessments
Total Due
$
$
���Lr��/�- � L. ��� ��
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$2100 per SAC Unit (Plans to MWCC for determination)
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: City of Fridley Attach
TYPE
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