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P - 43905Building Inspections 763-572-3604 763-502-4977 FAX DATE ! � "� � � �- �- a I 1 SITE ADDRESS � THIS APPLICANT IS: BUILDING RESIDENTIAL APPLICATION CITY OF FRIDLEY EFFECTIVE 1-1-201I � Permit No.: ' b '�� Received By:� Date Rec'd: � l� I YOUR E-MAtL ADDiZESS � � U �'� L=- � 1 "� '� � � A v� N� ❑ OWNER �CONTRACTOR PROPERTY OWNER/ NAME: � G ( T N °# S f� A� o N H E 1i C��.. S TENANT pDDRESS: I�� b S� AU�' ►`� � CITY � R� n � � Y STATEI� ZIP �S�f"�. I PHONE:�GS1•��1a— �3 � I CONTRACTOR SUBMIT A COPY OF YOUR STATE LICBNSE AND CERTIFICATE OF INSURANCE PROPERTY TYPE PERMIT TYPE TYPE OF WORK: DESCRIBE WORK BEING SIZE OF IMPROVEMENT ROOFING NUMBER OF $QUARES _ GARAGES PROPOSED SIZE: PROPOSED HEIGHT: SIDING ❑ Vinyl ❑ Aluminum ❑ Other NAME: I_I -�� STATE LICENSE # annuF�� a � KtNou�T�dN '- o lo � 9 � � (o fo 17� l�v� - o't� —�'�"�'l�F' �PCSiNGLE FAMILY/NEW CONSTRUCTION f� TWO FAMILY/NEW CONSTRUCTION O ADDITION 0 BASEMENT FINISN ❑ DECK ❑ NEW HOME CONSTRUCTION ❑ MAINTENANCE/REPAIR I WINDOWS IN EXISTING OPENINGS ❑Yes ❑No � OR FOR NEW OPENINGS-DESCRIBE SIZE OF OPENING CHANGES & � TYPE OF WINDOW TO BE INSTALLED ❑ GARAGE/SHED ❑ ROOF ❑ SIDING ❑ SWIMMING POOL ❑ ADDITION O HOUSE ONLY ❑ HOUSE & GARAGE ❑ ATTACHED GARAGE ❑ DETACHED GARAGE ❑Soffit ❑ Trim ❑ Fascia LOCATION OF WiNDOWS OF CERT NUMBER CITY �f NNgAP[x--lS STATEY� IP 7 T�'� FAX SIZE STORIES ❑ DRAM TILE ❑ OTHER FT BASEMENT REMODELING SUBMIT: 1. Existing Floor Plan 2. Proposed floor plan 3. List of structural members to be used FOR NEW CONSTRUCTION INCLUDING DECKS, ADDITIONS. & PORCHES SUBMIT: 1. Site Plan/Survey showing the existing structures and proposed project. 2. Two seu of construction plans 3. Energy Calculations FOR WMDOWS — PROVIDE U-VALUE AND MANUFACTURE STICKER ON WINDOW. ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS: G THE 1997 U.B.0 FEE SCHEDULE) TOTAL JOB VALUATION $__ ��,�)"'(�� OCCUPANCY TYPE Permit Fee Plan Review Fire Surcharge Surchazge License Surcharge SAC Charge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge Total Due $ $ $ �p� $ $ $ $ $ $ S'"'] , �1 i See Back Page for Fee Schedule 65% of Building Permit Fee .001 times the total job valuation .0005 x Permit Valuation Minimum $5.00 $5.00 (State Licensed Residential Contractors) $2230 per SAC Unit (Plans to MWCC for determination) ft+6ft= ftx$25=$ $450 Conservation Plan Review Fee Determined by Engineering Agreement necessary ( ) Non Necessary ( ) Make checks pavable to: Citv of Fridlev Attach 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 t start without a permit on site; that the work will be in accordance with the approved plan in the case of 11 ork whi e uires review d approva} of plans. f SIGNATURE OF APPLICANT PRIN�FGAME � R� � V R �� C�''ir DATE l b"��" 2 � �� APPROVAL INSPECTOR SIGNATURE /i / 11y�1lI ��i �, � � .; � . r 1 � A.. w ��1, . I • I .. • . � �� 1. ♦ � /,� � � � � . w, _ ± r.: � ,� � � A_ l ► L C S PG� �S l�lM �'Jl'1L' �I �l''1 ��1� � t�. h. � .. ��t GLL �C � • - - � �-- -- . � a� �r- �, . � I � � O�� 0 N� �� R -K i x -� _O ,, 0 � � � Z W ; � t�n � �' o �a�r � �� . � .:�-k � � �. �� ^ , �� .� �� Office of the Minnesota Secretary of State Assumed Name ( Certificate of Assumed Name Minnesota Statutes, Chapter 333 Read the instructions before completing this form. Filing Fee: $30.00 ��[��-�� I��I��ff�lll ��I��I 44737260002 Note: An Annual Renewal is required to be filed once every calendar year, beginning in the calendar year following the original filing with the Secretary of State. The filing of an assumed name does not provide a user with exclusive rights to that name. The filing is required for consumer protection in order to enable consumers to be able to identify the true owner of a business. 1. List the exact assumed name under which the business is or will be conducted: (ReQUiredl q S� �- L G 2. Principal Place of Business: (Required) � 7 3� � 2--�,. c� S Street Address (A PO Box by itself is not acceptable) � c ��.�Ppo��s MN SS�-o� City State Zip 3. List the name and complete street address of all persons conducting business under the above Assumed Name, OR if an entity, provide the legal corporate, LLC, or Limited Partnership name and registered office address: (Required) Attach additional sheet(s) if necessary. J�� w � a� � � �!� �� T 121 t L ��- ej�i (�'`�' J� S�� Name Street City State Zip � Name ' Street City State Zip � Name Street City State Zip 4. I, the undersigned, certify that I am signing this document as the person whose signature is required, or as agent of the person(s) whose signature would be required who has authorized me to sign this document on his/her behalf, or in both capacities. I further certify that I have completed all required fields, and that the information in this document is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this document under oath. ��^ �-- � — 2 � � 1 Signature (Only one nameholder or an authorized agent is required t� sign) Date Print Name and Title Email Address for Ofticial Notices OCT O,5 ZO��v Enter an email address to which the Secretary of State can forward official notices required by law and other notices: �- T V o � @ � M �- � �. , c_ o� �''L"��'` Seaetary of State ❑ Check here to have your emaii address excluded from reyuests for bulk data, to the extent allowed by Minnesota law. License lookup License/Certificate De�ail RESIDENTIAI BLDG License Type: CONTRACTOR Application No: 240438 Expire Date: 3/31/2013 Orig Date: Enforcement Action: 4/8/2011 NO License No: Status: Effect Date: Print Date: Na e: NEW WORLD ELECTRIC LLC Ad r ss: 2y3612TH AVE S MINNEAPOLIS , MN 55407 Phone: 612-229-9760 Fax: Other: Business Relationship Requirements Name: TUOTT, ARTHUR R Status: ISSUED Expire Date: 3/31/2013 Orig Date: 8/4/2006 Page 1 of 2 BC639226 _.._:_ ._� ,,,,y _ _ .--__-- ISSUED 10/7/2011 Lic/Reg No: QB136546 Application No: 265001 Effect Date: Insurance/Bond Requirements Work Comp: <EXEMPT> Policy No: Effect Date: 4/8/2011 Expired Date: Liability: ACUITY Policy No: K95532 Effect Date: 6/11/2010 Expired Date: 6/11/2011 https;//secure.doli.state.mn,us/lookup/licensing.aspx 10/14/2011