P - 80964za�� - � sa 9
Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'a: t I
763-502-4977 FAX EFFECTIVE I-1-2012
1 �
DATE� �� � � I tY�. ! YOUR E-MAIL ADDRESS .� ��'_ SG9 � l C " UC ��^J . % �
siTE a �� �ss �` $ / � 3'� � 1/ �� F� : �:J (ry .SS4 n1)
THIS APPLICANT IS: ❑ OWNER �jCONTRACTOR
PROPERTY OWNER/ �
NAME: D�.L j' Yj �� �� [" � C�f l� 1d
TENANT ADDRESS: 5 U I ,.� r� AI/n .�V Z= CITY I"i� CY(L" j� STATE%�'Ii� ZIP S.�J
PHONE: 7�lJ "r `J S� _„ ��J�� 9
CONTRACTOR NAME:�������i�,�..� �i`�ISl�J1 .
SUBMIT A COPY OF STATE LICEN3E #�S�k,� (� ��7 % LEAD CERT NUMBER."VA� ��C� �I% XP: Q , —
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: ��f�I G�ri.��!ti� ;Q/i� !L! CITY i%'j��5 STAT'Ei�ZIP=;St//�
INSURANCE pHONE ` � � FAX
PROPERTY TYPE J�:SINGLE FAMILY/NE CONSTR C ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �,OTHER J
❑ SWIMMINGPOOL +''-_ 'r"' ` , 1'6 T'/
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION L �Ln ���
❑ MAINTENANCE/REPAIR � REMODELING � � �,
DESCRIBE WORK BEING DONE: ,-e z '� r9 � r. J^ / �'= l =���'l`" �
SIZE OF IMPROVEMENT LENGTH �� WIDTH / r HEIGHT i � S FT
ROOFING /1 ❑ HOUSE ONLY
NUMBER OF SQUARES �` ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMTT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing sVuctures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTALJOB VALUATION $ �•/g7��1 OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ J��, �2,� See Back Page for Fee Schedule
��� , 3/ 65% of Building Permit Fee
$ �y, � .001 times the total job valuation
$ 2• 3 S� .0005 x Permit Valuation Minimum or .50
$ <,�Q17 $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 ( )
�. . 0 Make checks uavable 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 t wo � 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 r r�view and approval of pla�}s. /� Q
SIGNATURE OF APPLICANT ` PRINT NAME .S-'F�p%L �Yj .��`C �s�'n DATE `-r � � I � I �
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Minnesota Department of Labor and Industry
Construction Codes and Licensing Division
443 Lafayette Road N
Saint Paul, MN 55155
NOTICES
NOTTRANSFERABLE
CHANGE YOUR BUSINESS STRUCTURE
SUBMIT A NEW APPLICATION FOR NEW ENTITY
RENEW OR REPLACE INSURANCE POLICY
SUBMIT NEW CERTIFICATE OF INSURANCE
Licensing and Certification Services
Phone: 651.284.5034
Email: DLI.License@state.mn.us
Website: www.dli.mn.gov/ccld.asp
AMERICAN VALUE CONSTRUCTION CO
3801 QUEEN AVE N
STE 1 15
MINNEAPOLIS, MN 55412
NOTIFY THE DEPAR7MENT OF A CHANGE IN YOUR BUSINESS.
:Faiiure to do so, subjects you to administrative penalties of up fo �1U;400.
15-Day Notice Requirement—
• Change in business'',�
• Change in control, ow
• Change in business' I�
available online at
me number, or email address
rtners '
• Loss of or change in QUALIFYING BUILDER
*. ` Change in generaf liebility insurance or workers' compensation insurance coverage:
:immediafe Notice Requirement — Notification to DLI in writing
• Judgment Debtor. A licensed contractor has 15 days to provide written notice of the finding that it is found to be a judgment
debtor based upon conduct requiring licensure.
• Bankruptcy Petition Filed. A licensed contractaf nas 15 days to provide written notice that it filed a petifion for bankruptcy.
• Conviction Notice. A kicensed contractflr has:1 t} days to provide written notice that it has been found guilfy of a felony, gross
misdemeanor, misdemeanor or any comparable o#fense related to the license, induding convictions of fraud,
misrepresentation, misuse of funds, theft, cnminal sexual conduct, assault, burglary, conversion of funds, or theft of proceeds
in this or any other state or any other United States jurisdiction. __
YOk3R CERTIFtCATE IS BELOW THE PERFORATION. ' SHOV1f CEF�TIFICATE WHEN OBTAINING PERMITS. �
h11kNES6T��EPART�1ENTpF RESIDENTIAL BLDG CONTRACTOR :
,_
}� LABOR 8t 1NDUSTk�Y
Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road N St. Paut; MN 55155
Website: www dli mn aov/ccld aso Email: dli.licenseCa�state mn us Phone: 651.284.5034
This is to certify that the sertificaie: holder is licensed as a RESIDENTIAL BUILD{NG CONTRACTQR in the::state of 1Ylinnesota and is in
cornpliance with Minr�esota Statutes 326B.805, and may build residential real estate, contract or offer to contract with an owner to build
residential real estate; and conttact or offer to contract with an owner to imprave existing residential real estate; provided the
responsib]e individual is at alt<times a QUALIFYING BUILDER and the certificate holder maintains compliance wtth the required general
liability insurance, and workers' compensation laws.
License : RESIDENTIAL BLDGCONTRACTOFi �
Lic Number : BC636607 AM'ERICAN VALUE CONSTRUCTION CO i
Effective Date : : 3801 4UEEN AVE N B
Expiration Date : 03/31/2013 �
STE 115 �
' MINNEAPOLIS MN 55 T
, 412
VERIFY UP-T0-Q,4TE STATUS, BOND, AND INSURANCE INFO AT www.dli.mn.qav/ccld/E:icVerifv asp (ENTER NUMBER).
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