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Inspections i�ESII)�NTIAL APP�ICA�IOIl� t�ecei���� r�y --- --
763-572-3604 CITY �F FRIDLEY Dat "�: ��� 1�' ��
763-502-4977 FnX ��
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CONTRACTOR
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YOUR SI�ATE LIC_F.NSE
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PROPER'TY' TYPE
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AI,L FEES ARE BASED ON VALUATIQN, IIVCLUDING TNE COS'I' OF LABOR AND MA"1'ERIALS:
USIN(y�' ' li�'f.j997 U.B.0 FEE SCNEDEiLE}
TQTAL JOB VAI.UATION S -/� ���% OC'CUP.A1tiCY" TYPE
Permit Fee b ��Q �. 2-5 See Back Page for Fee Schedule
Ptan Review $ 65°rb of Bu�ldin� Penmt Eee
Firc 5urcharge $ �.001 times thc total job ��aluation
Surcharge $ C� .0005 x Permit Valuation Mimmum $5 00
License Surcharge $ $5 00 (State LieerLSed Residential Convactors)
SAC Char�e $ $2230 per SAC' [?nit (Plans tn MWC'C Fnr determinatinn)
Curb Cut f•'scrow $ ft +(� ft= ft x�24 =$
Erosion Control $ $450 Conservation Plan Re��iew
Park Fee $ Fee Determined by Fngineer?ng
Sewer viain Charge $ Agreement nec�ssary O Non Nec�sary O
T�ta� Due $ I(l''� �via�:e checi:s oavabie to: t:itv of Fridiev Attach
uiations
T}iFS [5 AN AI'YLIC.A I IUN FOR A i'EFLMlI'-�OI VALti) UN`fl[. l'K(X'ESSED
1 hereby appl4• for a bu,iding permit and I ackno�•ledge 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 wit}i the Minnesota C'onstructi�n Codes; that I understand this is not a
permit but ot13y an application f'or a permit and work is not to start without a ermit on site; t t the work witl be �« accc�rdance with the
approved plan in the case o 11 w which r uires re�•ie and approval of pla �j� !/ -—
SiG:VnTURl: C� AP'f'I.�CAN"f PRiNT NAM!? DA"I'E
AYYRC)VAL [NSPECTOR SI AT�I�`R �•.
PLEASE NOTE: SEPARATE PER14II' . ARE REOUIRED FOR PI.,UMBING. ELECT AL A:�D MECHAMCAL Vti�ORK
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FR�ID�Y
FnIDLES' MUNICIPAL CENTE.R • 6431 tJNiVERSITY AVE. N.E. FRIDl.,EY. M': SS432 -('63) j)1-gp9p. FAX (7ti3) 571-1287
BUILDING PERMITAPp�ICANT: PROPERTY OWNER
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�� y� _, understand that the State of Minnesota
requires that ail resi ntial building contractors, remodelers and roofers obtain a state
�icense unless they qualrfy for a spec�c ex�mp � from the licensing requirements. As
the owner of the property at ', ,�r A��
am exempt from the state licensing requirement only d i am not building or impro�ving i
this property for purposes of resale. By signing this document, I attest to the fact that I
am improving this house for my own use and do no; iniend to seil it, f hereby claim to
ae exempt From the state iicens+ng requirements because I am not in the business of
building or remodelfng on speculation or for resale and that the house for which I am
aPP�Ying for this permit, isi the first residential structure I have built or improyed in the
past 24 months. I also acknowledge that because I do �ot have a state license, I forfeit
any mechanic's lien rights to which I may otherwise have been eniitied u�der Minn.
Stat 514.01.
Furthertnore, I acknowtedge 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, remodeting, andlor rooRng activity is
a misdemeanor under Minnesota law, and that I would forfe+t my nghts to
reimbursement from ihe Con,ractor's Recovery Fund in the Pvent fhat any co�Vac,�lors i
hire are unlicensed.
I have also been informed and acknowledge that by listing myself as the contractor (or
this project, I alone will be responsible to the City of Fridley for compliance with a!�
aPP���bie buiiding codes and crty ordinances in connection with fhe work being
pertormed on this praperty.
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