P - 84315Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE i-i-zoiz
DATE lO/Z3/�Ii YOUR E-MAIL ADDRESS
SITE ADDRESS W a 7� 0/ �C�G'f n%E
THIS APPLICANT IS: ❑ OWNER LACO�NTRACTOR
PROPERTY OWNER/ NAME:_ l�u gS G/� �j�5�'i4 CC ItJ
TENANT � � �-y� .� �' w r�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
ADDRESS: p� % cS 'fC
PHONE: �� 3 '� J�7'�j�— �(v�
NAME: T/N iTN %JI G I
STATE LICENSE # 4J C S�� (f �
CITY FR�d �£
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LEAD CERT NUMBER
CITY GfJ�c7 �
PHONE (p�( '� S'Y� '�� y,1 FAX lp S� -� 3YIS —'
�HGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIE5
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING C3�6Y't ER f,�QOIC
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR LL9 1�EMODELING
ATE%yf/lI ZIP.
Exr: � '�U" ! S
STAT��ZIP ta a ���
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DESCRIBE WORK BEING DONE: ,i-/vf'7-�f.�� /QCRIe GN%x�/ QQD %� /N ,D R�C �X�.tTif� ��~'��L� �
SIZE OF IMPROVEMENT LENGTH ~ WIDTH �7 N HEIGHT I� �/ S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 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 SUBMIT
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2, Two sets of constmc[ion 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 VALUATTON, INCLUDiNG THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Perntit Fee $ L i.(O� See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ '"2 n .001 times the total job valuation
Surcharge $ � .0005 x Permit Valuation Minimum or .50
License Surcharge $ � dD $5.00 (State Licensed Residential Contractars)
SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft + 6 ft = ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Detennined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ � Make checks a able to: Ci of Fridle Attach Sti ulations
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 an codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati p rmit w rk is not to t ithout a permit on site; that the work will be in accordanc with the
approved plan in the cas of all '�vie oval of plans. l, �,%�./r
SIGNATURE OF APPLICA - PRINT G;S ���"`'i� aI`�ATE `� Z I�
APPROVAL INSPECTOR SIGN
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From: 65t6366793 Page: 2/4 Date: 10/25/201212:05:03 PM
�, FOffn.A�p�om10MB No. 2070-0165 F,xptreg 70f31t11
�� APP'UGATION FpR FtRMS
U.S. �NVIRONM�NT�qL FSROTEC'f1ON /AGElVGY TO CONO�G'f LEAD-�qsED PpIN"E ACTIYITI�$ ANDJOR R�NOYATiQ►�$
frnportant: Thls app;ication Is required by 4a CFR §745_$9(�f for renov2�tions and is a substituta for the (etter requlred by
§745.226(f}(2) for abaternent. Cansuif the instructions for fitms appi}+�ng fpr c;ertification to Conduct l��d-based activi#igs Of �novations.
For abatement activitles, persons seekEng indivldual certiflcaticrn ahauld use the Applicstfon tpr Ihdividuals fnstead of fhis ft�rrn, Pfeaso
�ill out �ii se�tion$. Type or print respans�s in black or blue ink only,
A. Appl[c�tipn Type (seiect pn[y ohe box trom C3ption i,, 2, 3 ar 4 0[ Section A}
1,
2.
3.
'1: �ntovation. Reaair_ and Pair�in RRP snd pust Semp��no Teehnitie�l Firm Certi�tc�tion
Rec�G2tio� --
or Renpvativn, Repair �nd Paintin� Firtn CetGfic�tivn {$300)
or
2: �Siti�'III�1'I.��IAF]htP171PYfY RICI[ daeacew�a.w1 e....a �.,.. .....�:--� -- w �_._ . ...-..-...-, ... .. . . ._
���� Rec�catian
or
��1 Reb��ation
or
LIBt abatement jutisdiction(s);
Abatement Firm Certificatian ($550 fo� flrst Jurisdiction and
�35 for aach additional juri6diction — flyt jurisdictiart(sj below)
Gombinatio:t AbatemenVRRP Firm Certific�ativn (�550
fpr i�i�p end one abat�m�nt jurisdicfion, $�5 fo� eaeh
addi#ionai ahate�nent junsdictian — tist abatement jurisdicttcn(s) be�orv)
1 } (S55o) a) t$sss� s) (Se2o)
(Please nots, if appiying for more th�n three jurisdiCtions add �n �dditiorial $35 tor each jurisdictlbn and Eict Utem on a
Sqpatate sheet of paperj
Update firm inforrnafiion (no fee requlr�d)
Add ahatAment jurisdictipn (�35 per abatement jurisdiction)
tist abatement jurisdlction(s) being added to your existing cerq?i�ation:
�) � ($35) 3l l��n► �i
4. O�tion 4; Re lace �rtifreate
Replace Certificate (S15)
B. Ente� taW F aPPlicatfon fee ffi �G�. �
Note 1: Sse inahuctions for add'+tionel fe� inform&tlon and examples of requlred fees.
Note 2; If you are a fcd�raily recoynFZed Indian Tribe seeking Certiiication a$ a firm eheCk yes in the questio� below and see Fses
Schedule it► the Instru ' ns W�i�tg��ne fee requlreti.
�'es N Indicat� wnether ypu are a fedi�atfy-recogni2ed Indfan Ui}7e seeking Cet'tification aS a ffmi.
�'.. %�D!}��Cdli �(1fe1'Matinn
Name o( Firtn:
Bus�ness Addresa: _
Address, Sui#e Numb6f (Please no
Mailing Address: _ _ .�ffl!"�.�
Qif ditfsrent from abova) Slreet Atldrees, Suite Number
Name of AitesEing !nrlivir#ual:
Ciry
�Y St�ats
If�
code
Cod�
��t �i''� - Middfe .
Flrm s Fhone #; � ����„_.'f � �� �:� Attesting lndivitfusl's P�One #: ���`�'/~l�''*y'g� ��
Attest'tng Individua!'s E-mail Addtess:
ERA Form a5oo-27 (Rev 9hN )
�totz
From: 6516386793 Page: 3/4 Date: 10/25/201212:05:04 PM
Fam approveQ OMB No. 2pip.p195 �¢�6ea 1W31/17
Once r,.�rtiied your firm wif[ be listeclQ EPA's w�b basect sear�ch #ool. Please select the type of servlce{s) your firm wi1!
provide: �'
Rer�ovati�n Evaluation Lead Abatement
E. I.ead-Based Patnt Act�v�ty ar Renovstion Violation�s]
I?oeS the firm hav� ar�y past, preseni, or pending lead-bas�d pairrt violativna of EPA,
StFSte, U.3. taRitory, or Indian tribat land(s) r�gutations? If yes, pfease attach a written expEenation.
F Certtfication Statement
Yes � No
I heroby attest and a#firm the follou�ing:
� The infisrmat€�n inGuded on tl�is applicsUon, induding any attachmen=S, Is frue a�l[� sccurdte to the best of my tyelief anB
kriowled�e.
• ?'his fri'm sh$!t ol�ly employ appropliately qualified irtdfviduals to conduCt lead-bas�Bd paint aCtivities and Cenovati0r18.
- 7his firm and iis empfoye�s shaH inllpw the work practice shandards set forth in 40 CFR § 745.227 for oo�duoting teacf-based
psint acFivities tbr 40 CFR § 745.$5 for cpnducting renovatiqn5 8t ell times.
• I acknowledge that any certl�Ca;ion issued put5uant tq thls appliCation, in�lwding any �ttachm�r�ts, will be subject to rev9cation
1f Issuence was basetf on incom�ct or inadequate fnformatlqn that materiafly affeCted the decisior� tp issue the certificatipn.
f/i- !►�IT/ • / f�'I'�+.����,r�
Sign�ture
(Pfease slgn IegiblyW�(n the b0und8ries Of the box ebov�,)
Ti#le
Signed
rz.
PrivseyAd 5tetement: 'fhfs g�tement Ig provided pu�suant m the Privacy Act af 197d, 5 U.S.C. §SSZa. The autnar;ly tc,r couecu�g thia informat6vn Fe <o
C.F.R, Pert 7a5, a�d 19 U.S.C. §§Z68Z end368a. The i�amat� coileG�Cd ort this tprm wiU he used to establish the spp�ICanYs eligibil(prfor c�ertlflqyon ro
tdndua legtl.baeed A�i�lt ectiu�tles aRd renovatiqna in taegQt huuatng a�d chilu-oxup�ed fadlltieS. Diadneyre of this infOrn'�tion is vCtvnt2ry, hawpyer, tha
t�lure tp provide thtg infamatlqn may dH�y or prevent a� applKanKS certMir,a}pn. 7hlg info�ation may ye disdvsad i� epprop�ata e�O Um� p��}bn�
ta E?k empfoyees, ppn�c�pfg, �rarEtees pr othera wh� peKam,ing dudeg �� are cpmpatible wRh thapurpose Ior wfiich this infomiation i� �Ileaea �n�t
wheillhia infamation is necaveery m onn,pt�te the task; a mar�ber at congreas in rasppnse to e repusst made w;th yowr conserrt and on your behatf; to
ePP�oPriats taw e�AOn�mene agendes resPOnalble fw investigaGny. enfwdq9. Woeeeu6n9 or IrnplemenUng epecifw atatutea, wdsa or regulationa end lhis
infam�n ia retev�t W V�el +esponatbility; an eppropriate eejudicative ootly when au�h dsdoeurC is wmpatiW� �� �e purpase fa� which thie InTa,moq�
is col�etted antl th� �PA ar tha Un$� S�a�ps hBa en i�tereat in the Proceetling; gntl the O�periment d Ihe Trea3Ury, the Gen�rdl Servlt� q�jmin�tYdOon, ihe
Gene►9f Appa�ntlng q(��q and �1,er Petle,ai, Stste, and Local qq�ies far au�hahzed ac�iviriag rob�ad to this irdortnetion.
Bef�re you m�ll ynur application anc� certiffc�tian fee, m�lce swio that you have;
• Filled ou{ ap app}icahle sections pf the appJicatiop
• SPgrted ancl dated the application
• Made a copy of yaur appfication {or yaur fites
• �ndo8ed #he sppropnate certification fees (check or money order}
• Make Check payable ta U.S. �PA
• Printed "Lead Arogram User Fe�s• 4n the Ch,eck ar Mo�sy arder
• Far more fr�formation, see thE fees section of the instructions
Maif origlnal compl�ted appJicatian, 9uppvrting maberials, Bnd°the certt}iCation fee foc
U.S, EPA
Lsrac! UseF Fees
P_O. F�ox 979072
SL �.ouis, Mp 63197.9U0U
EPA Forrn 85pp �'► (Rev 9li 1 j
Page 2 oP 2
From: 6516366793
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Fram: 6516366793
Page: 4!4 Date: 10/25f20121'2:05:04 PM
� En�rir�►�mer��a1 Tr�ining ln�titute
�5p�! 2nd Avenue �torth S#op F�273
Gra�d �ark�, NC� 58202-8273
7p 1-777-�0384
www.eti.urtd.edu
.�/O� N�%c��rl
Twir� City Home F2emadeling (r�c.
7710 Centra! ave N�
Spring Lake l�ark, MN 55432
Certificate af Atter�dance and �uccessful Completia►n
LE�#D RENOVATGR INfT1AL��NGL�SH
'!'er 40 CFR Part 745.22�
on
March 20, 2Q1 Q
Cours� Location: Bloomingt4n, MN
Exam Uate; March 2p, �Q�4
Certific�te No: R-1-8864-i0-Q1080(032q�
�xpir�tion l�ate: Mar�h 20, �045
.�
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Enviranm�:ntal Training Ins#itute