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P - 43648Building BUILDING PermitNo.: ��%����° y Inspections RESIDENTIAL APPLICATION Received By: � 763-572-3604 CITY OF FRIDLEY vate Rec'c1``/� 763-502-4977 FAX EFFECTIVE 1-1-2010 DATE ��i `/ 3' � C, YOUR E-MAIL ADDRESS ��'1 Ll,t t C�C /� C� , .�� /�'�A iG . C'6/��( sITE ADDxESS _ _ �7 _S 3 �1 � �� .S�-, � f : � , THISAPPLICANTIS: �OWNER ❑CONTRACTOR PROPERTY OWNER/ HAME: ��_ ,� _ �-� t� E TENANT ADDRESS: �53� �� ,S9" N, �, CITYFi�f n CEy STATEM ZIP� PHONE:__']I�3-' ��%� — �aZ�� CONTRACTOR N�ME: SUBMIT A COPY OF YOUR STATE LICENSE STATE L[CENSE # EXP DATE AND CERTIFICATE OF ADDRESS: CITY STATE ZIP INSURANCE PHONE FAX PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE ❑ TWO FAMILY/NEW CONSTRUCTION STORIES PERMIT TYPE ❑ ADDITION O GARAGE/SHED ❑ WINDOWS '�BASEMENT FINISH ❑ ROOF ❑ DRAIN TTLE ❑ DECK O SIDING ❑ OTHER � SWIMMING P�L TYPE OF WORK: ❑ NEW HOME CONSTRUCT[ON ❑ ADDITION ❑ MAINTENANCE/REPAIR ❑ REMODELING DESCRIBE WORK BEING DONE: 7'7� a�l �,c� �SE/VI��iJ! SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT �tOOFING �, ❑ HOUSE ONLY BASEMEN'f REMODELING SUBMIT: N[JMBER OF SQUARES p HOUSE & GARAGE I. Existing Floor Pian 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 ADDITIONS. & PORCHES SUBMIT: ❑ Aluminum ❑'Trim 1• Site Plan/Survey showing the existing structures and proposed project. � O�her � Fas��a 2. Two sets of construction pians 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 TOT. �►1,1. r�r�a Ax� Isa��;u Vlv vALUA l'lU1V, 11VC:LUll1N(= "1'HE (:U5'1' UF LABUR AND MATERIALS: �1 (US�,ZVG THE 1997 U.B.0 FEE SCHEDULE) JOB VALUATION $ o��f )U , Ci) OCCUPANCY TYPE Permit Fee Plan Review Fire Swcharge Surcharge License Surcharge SAC Charge Curb Cut Escrow Erosion Control Park Fee Sewer Main Charge Total Due $ See Back Page for Fee Schedule $ 65% of Building Permit Fee $ .001 times the total job valuation $ .0005 x Permit Valuation Minimum $.50 $ $5.00 (State Licensed Residential Contractors) $ $2100 per SAC Unit (Plans to MWCC for determination) $ �+6ft= ftx$24=$ $ $450 Conservation Plan Review $ Fee Determined by Engineering $ Agreement necessary ( ) Non Necessary ( ) $___ I('� i� Make checks payable to: City of Fridley Attach THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED I hereby apply for a buitding 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 wil( be in accordance with the approved plan in the case of all work which requires review and approval of plans. SIGNATURE OF APPLICAN'�16p��_ l;�^`�. PWNT NAME �'�/E � W �� DATE �`-3%O . � �i BUILDING PERMIT APPLICANT: PROPERTY QWNER I, � �, �`� Gc , understand that the State of Minnesota requires that all residen ial building contractors, remodelers and roofers obtain a state license unless they qualify for a specific exemption from the licensing requirements. This license requirement applies to owners of residential real estate who build or improve such property for purposes of speculation or resale. By signing this document, I attest to the fact that I am improving this house for my own use and am not building or improving this house for the purpose of reselling it. I hereby claim to be exempt from the state licensing requirements because I am not in the business of building or remodeling on speculation or for resale and that the house for which I am applying for this permit, located at "7 S3 � �#.�vr- 9U. � , �"2, � � �,� , is the only residential structure I have built or improved in the past 24 months. I atso acknowledge that because I do not have a state license, I forfeit any mechanic's lien rights to which I may otherwise have been entitled under Minn. Stat. §514A1. Furthermore, I acknowiedge that I may be hiring independent contractors to perform certain aspects of the construction or improvement of this house and I understand that some of these contractors may be required to be licensed by the State of Minnesota. I understand that unlicensed residential contracting, remodeling, and/or roofing activity is a misdemeanor under Minn. Stat. §326B.082, subd. 16 and can also result in a fine of up to $10,000. I further state that I understand that the filing of a false statement with The Citv of Fridlev may also result in criminal prosecution and/or civil penalties to applicable city ordinances andJor state statutes. I have also been informed and acknowledge that by listing myself as the contractor for this project, I alone will be responsible to The Citv of Fridlev for compliance will all applicable building codes and city ordinances with the work being preformed on this property. v�� ignatur o Property Owner � � 3 — /cU Date For questions or information on contractor licensing, or to check the licensing status and enforcement history of a particular contractor, call the Minnesota Department of Labor and Industry, Construction Codes and Licensing Division, at (651) 284-5069. 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