P - 83507Bu11d1rig $UII,�jN(i Permit No.:,; �l� �G` �
Inspections RESIDENTIAL APPLICATION Received gy�lil(I�C�'=-
763-572-3604 �° � c
763-502-4977 FAX CITY OF FRIDLEY ������:� '� �� �
EFFECTIVE 1-1-2012
DA'TE _�� �% � /� YOUR &MA[L ADDRESS � y/� /,� ����� ��c �? S� �� r..f L f � 6�'J�T� . < <' �'�'i
S1TE ADDRESS � / ��f �"f� ,/�i�.` �^d ��G/R�I/ �✓'I�� S� 5�..1-%
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THIS APPL[CANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: ��N � C, I C( ' � G>vl
TENANT ADDRF,SS: l S I�C."� ~/�i CiTY M�F(_C L*�L' ��c`; STATEJI'Lf ZIP SS -3!�
PHONE: •.'iG'+•3 `S�-C� "°" X �� � _
_ �� � ,�
CONTRACTOR NAME: C..� Cc, � � �«/ � ��( � � � ; ;
SUBMIT A COPY OF � � � �
YOUR STATE LICENSE STATE LICENSE # ��� ,� �.�iC?'��/ LEAD CERT�IYLIMBER EXP:
AND CERTIFICATE OF ADDRESS: `� � 7SJ��,SSt��c,!�c%� ��'J C[TY t�P. 3S STATE-'�'%��[P,7SI7 �
INSURANCL PHONE �c-��� —/�' �d "GG-� �''i O FAX 7C" s' S/.1 Y` D`� �
PROPERTY TYPE $rSINGLG FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHCD f$WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN T[LE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCF./RGAAIR �( REMODELING
DESCRI6E WORK BEING DONF,:_!`' j i� 5 S i ti'- �'�i U=-�"
SIZE OF IMPROVEMENT LENGTF�I ..< %�� '"°`�' W1DTH S/G �'7tiIIElGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODEL[NG SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE I. Existing Floor Plan
G.4RAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structura] members to be used
PROPOSED HEIGHT:
SIllING FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT
❑ Vinyl ❑Soffit SID[NG/SOFF[T/FASCIA �_ Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED. ❑ YES ❑ NO and proposed project.
❑ Other � Fascia 2. Two sets of construction plans
WINDOWS 3. EnergyCalculations
IN EXISTING OPEN[NGS ❑Yes Id1No LOC�T,j�V�� WINDOWS� '� POR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPEN WGS-DESCRIBE SIZE OF � J ir �/� � MANUFACTURE STICKER ON WINDOW.
OPENINGCHANGES& 9 ��--"��',��;jK
TYPE OF WINDOW TO BF. INSTALLED C``r;y��'`'�%'1 f MIMBER OF WINDOWS
ALL r L� C,� AKL' ISAJ�ll VlV VALUA 11lJIV� 11vl;LUUl1Vl; I H� l:Ua l UN LAKUK AlVll MA'1'N:IZlALS:
(USING�'H� 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ��"�" OCCUPANCY TYPE
Permit Fee ,
Plar1$eview �hU ; i�' � �-
�ire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ` See Back Page for Fee Schedule
$ ��• j 65% of Building Permit Fee
$ � " .001 times the total job valuation
$ _ 1i .0005 x Permit Valuation Minimum or .50
$ ` �> $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ � ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �'1 � J. Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERM(T-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I ack ledge that the information above is complete and accurate; that the work will be in
conformance with the ordinanees and co of e C ty of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application or permit d w rk 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 w k�ich 'r s review and approval of plans /
SIGN�'IUREOPAPPLICANT� ^�"� --� " PRINTNAME 1,�;i��",�i� �_�"-+'"��j DATE ��- i�-:!i
APPROVAL INSPECTOR SIGNATUKF `
PLEASE NOTE: SEPARATE PE �, S RE REQ IRED FOR PLUMBING, ELECTRICAL AND� MECHAN�CAL WORK
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GETTY CONSTRUCTION LLC
GENERAL CONTRACTING
13275 BASSWOOD �ANE 763-428-9050
ROGERS, MN 55374
Pay to the G �' � �
19475
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����� APPLICATION FOR FIRMS
U.S. ENVIRQNMEIVTAL PROTECTION AGENCY TO CONDUCT LEAD-BASED PAINT ACTIVITIES AND/OR RENOVATIONS
Importarrt: This appiication is required by 40 CFR §745.89(a) for renovations and is a substitute for the letter required by
§745.226(fj(2) for abatement. Consult the instructions for firms applying for certification to conduct lead-based activities or renovations.
For abatement activities, persons seeking individual certification should use the Application for lndividuals instead of this form. Please
fill out all sections. Type or print responses in btack or blue ink only.
A. Application Type {select only one box from Option 1, 2, 3 or 4 of Section A)
1. IOption 1: Renovation. Reaair, and Paintinp tRRP and Dust Samplintl Technician) Firm Certification
Initial Recertification
2.
or
Option 2: Abatement (Abatemen
Initial Recertification
� or Q
Initiat Recertification
� or �
List abatement jurisdiction(s):
Renovation, Repair and Painting Firm Certification
Abatement Firm Certification ($550 for first jurisdiction and
$35 for each additional jurisdiction — list jurisdiction(s) below)
Combination AbatemenURRP Firm Certification ($550
for RRP and one abatement jurisdiction, $35 for each
additional abatement jurisdiction — list abatement jurisdiction(sj below)
1 } (;550} 2) ($5S5) 3} {5620)
(Please note, if applying for more than three jurisdictions add an additional $35 for each jurisdiction and list them on a
separate sheet of paper)
3. ( Op�n 3: Amend E�cistina Certification
Update firm information (no fee required)
� Add abatement jurisdiction (�35 per abatement jurisdiction)
List abatement jurisdiction(s) being added to your existing certification:
1}
4. Option 4: Ren(ace Cer#ificate
� Repiace Certificate ($15)
$35) 2) {$70) 3) ($105)
B. Entertotal application fee $ �dU �°
Note 1: See instructions for additional fee information and examples of required fees.
Note 2: If you are a federally recognized Indian Tribe seeking certification as a firm check yes in the question below and see Fees
Schedule in the instnactions to determine fee required.
Yes � No � Indicate whether you are a federally-recognized Indian tribe seeking certification as a firm.
C. Applicant Information
Name of Firm:
°or: % L C�
Business Address: I 3a'7� �aSS W o� � �o�
Street Address, Suite Number (Please no P.O. Box) City
�/�1 .s� 7w
5tate Zip Code
Mailing Address:
(if different from abave) Street Address, Suite Number City State 7rp Code
Name ofAttesting Individuat:
Firm's Phone #: �G � f �� �'�� ext
Attesting Individual's E-mail Address:
�es
Middle
Individual's Phone #: �� " 77�' 66�( ext.
Uc �"j �G re�/i%�• Cov�
EPA Form 8500-27 (Rev 9111) Page 1 of 2
� oan nyN� uvcu vw'o �vv. cvr �-ti wo Cxp�res 7 W sNl 7
Once certified your firm will be listed on EPA's web based search tool. Please select the type of service(s) your firm will
provide: �
Renovation ❑ Evaluation ❑ Lead Abatement
E. Lead-Based Paint Activity or Renovation Violation[s]
Does the firm have any past, present, or pending lead-based paint violations of EPA,
State, U.S. territory, or Indian tribal land(s) regulatians? If yes, please attach a written explanation.
F Certification Statement
�► � ��i
.
I hereby attest and affirm the following:
• The information included on this application, inctuding any attachments, is true and accurate to the best of my belief and
knowledge.
• This firm shall only employ appropriately qualified individuals to canduct lead-based paint activities and renovations.
• This firm and its employees shal� follow the work practice standards sef forth in 40 CFR § 745.227 for conducting lead-based
paint activitiss ar 40 CFR § 745.85 for conducting renovations at all times.
• I acknowledge that any certification issued pursuant to this application, including any attachments, will be subject to revocation
if issuance was based on incorrect or inadequate information that materially affected the decision to issue the certification.
Individual's Signature
(Please sign legibly within the boundaries of the box above.)
C6 4c�i�✓� e r�'
Title
Date Signed
a
Privacy Act Staterr�eM: This statement is provided pursuant to the Pnvacy Act of 1974, 5 U.S.C. §552a. The authority for collecting this information is 40
C.F.R. Part 745, and 15 U.S.C. §§2682 and 2684. The information coflec�sd on this form will be used to establish the applicarrt's eligibility for certfication to
conduct Isad-based paint activities and renovations in target housing and child-occupied facifities. Disc(osure of this information is volurrtary; however, the
failure to provide this infomration may delay or preverrt an applicanYs certification. This information may be disdosed in appropriate and limited circumstances
to: EPA employees, contractors, grantees or others when perFonning duties that are compatible with the purpose for which this information is collected and
when this irtformatio� is necessary to complete ths iask; a member of Congress in response to a request made with your consent and on your behalf; to
appropriate taw ertforcemerrt agencias responsible for investigating, enforcing, prosecuting or implementing specific statutes, crodes or regulations and this
irrformation is relevaM to that responsibility; an appropriate adjudicative body when such disclosure is compatible with the purpose for which this information
is collected arn! the EPA or the United States has an interest in the proceeding; and the Department of the Treasury, the General Services Administratio�, the
General Accouniing Office and other Federal, State, and Local �enaes for authorized activities ralated to this information.
Before you maif your application and certification fee, make sure that you have:
ti
�
�
Filled out all applicable sections of the application
Signed and dated the application
Made a copy of your application for your files
� Enclosed the appropriate certification fees (check or money order)
�
'.. Make check payable to U.S. EPA
• Printed "Lead Program User Fees" on the check or money order
• For more information, see the fess section of the instructions
Mail original completed appfication, supporting materials, and the certi�cation fee to:
U,S. EPA
Lead User Fees
P.O. Box 979072
St. Louis, MO 63197-9000
License lookup
,� ,. . ,� ,� � . �,
License Type:
Application No:
Expire Date:
Orig Date:
Enforcement
Action:
RESIDENTIAL BLDG CONTRACTOR
240633
3/31/2013
4/20/2011
NO
Name: GETTY CONSTRUCTION LLC
Address: 13275 BASSWOOD LN
ROGERS , MN 55374
Phone: 612-670-4864 Fax: Other:
Business Relationship Requirements
License No: BC639304
Status: ISSUED
Effect
Date:
Print Date: 10/7/2011
Name: GETTY, STEPHEN Lic/Reg No: QB128068
Status: ISSUED Application No: 259193
Expire Date: 3/31/2013 Effect Date:
Ori� Date: 1/4/1993
Another Lookup?
https://secure.doli.state.mn.us/lookup/licensing.aspx
Page 1 of 1
v �� ��
4/12/2012
�t.� ��
MINNESOTA DEPARTMENT OF
� LABOR & INDUSTRY
CONSTRUCTION CODES AND L{CENSING
Po eox 6421 7
0 ST. PAUL, MN, 55164-02 i 7
NOTICES
LICENSE IS NOT TRANSFERABLE
CHANGE OF BUSINESS STRUCTURE
YOU MUST GET A NEW LICENSE
A CHANGE IN INSURANCE POLICY
REQUIRES A NEW CERTIFICATE OF
INSURANCE TO BE FILED
�'- �"- ��;�','� �
Construction Codes and Licensing Division
Phone: {651) 284-5034
Email: dli.license(a�state.mn.us
Website: www.dii.mn.qovlccid.asp
/Ifl
GET1Y CONSTRUCTtON LLC
13275 BASSWOOD LN
ROGERS, MN 55374
YOU MUST NOTiFY THE DEPARTMENT OF CHANGES IN YOUR LICENSED BUSINESS.
Failure to do so, subjects you to administrative penalties of up to �10,OOQ.
't 5-0aY Notifrcation Requirement. Licensed contractors must notify DU in writing within 15 days of the date that any of the following
changes to tk�e license oceur du�ng the license period. Information and forms to make changes to the<license are available online at
www.dli.mn.gov/ccld/LicUpdate.asp.
• licensed business' physicat street address, phone number, and mailing address.
. Change in licensed contractor's control, ownership, o�cers or directors.
• Change in licensed contractor's legal name and/or assumed name.
• Loss of or change in Qualifying Person.
Judqment Debto� Notice. L.icensed contractors must notify DLI in writing within 15 days of the finding that the contractor is found to
be a judgment debtor based upon conduct requiring licensure per Minn. Stat. §§ 3265;802 to 326B.$$5.
Bankruntcv Petition Filinq Nofice. Licensed contractors must notify DU in wrifing within 15 days of fiting a petition for bankruptcy.
Conviction Notice. Licensed contractors must notify DLI i� writing within 10 days if the licensee has been found guilty of a felony,
gross misdemeanor, misdemeanor, or any comparabte offense related to residential contrac6ng, including convic6ons of fraud,
misrepresentation, misuse of'funds, theft, crimina! sexuat conduct, assauft, burglary, conversion of funds, or thett of proceeds in ihis or
any other state or any other U�ited States jurisdiction.
Your license certificate is below the pertoration. Show license ce�tificate to when obtaining building permits
IdINNFSOTA DEP0.RTMENT OF
� LA80R & INDUSTRY
CON57RUCTION GODES AND UCENSiNO
PO BOX 64217
�� 5T. PAUL, MN� 5518+W2 f 7
Constru�tion Codes and Licensing Division
Tetephone; {651 } 2845034
E-mail address: dli.license�state.mn.us
Website address: www dli mn_gov/ccld asp
RESiDENTtAL BUILDING CONTRACTOR Lt�ENSE
Legal Name: GETTY CONSTRUCTION LLC
oBa:
Address: 13275 BASSWC30D LN
ROGERS, MIV' 55374
License Identificadon Number: 20639304
License Expiratioo Date: 03/31/2013
Qualifying Person: STEPHEN GETTY
8usiness Structure:
UMITED LIABIUTY COMPANY