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B - 48311Building BUILDING Permit Ivo.: Z�`L{)0 Inspections RESIDENTIAL APPLICATION Received sy: 763-572-3604 CITY OF FRIDLEY Date Rec'ct: �- �' 763-502-4977 FAX EFFECTIVE 1-1-2012 DATE D� O I Z YOUR E-MAIL ADDRESS SITE ADDRESS � G �PYI C' � h� � �I< ( d /�1 3 Z THIS APPLICANT IS: WNER OCONTRACTOR PROPERTY OWNER/ NAME: M V�b °u� �� Ic�c C T'ENANT p�DR�ss: �.�,,.� crrY .� S'rArE ZIP PHONE: � G, � `%i��o SZ/,,��- CONTRACTOR xAtvtE: SUBMIT A COPY OF STATE LICENSE #� / LEAD CERT NUMBER EXP: YOUR STATE LICENSE AND CERTIFICATE OF ADDRE3S:�'J� CITY STATE ZIP 1NSURANCE pH0 E ` FAX PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTIQN _, SIZE O TWO FAMILY/NEW CONSTRUCTION STORIES PERMTT TYPE 0 ADDITION ❑ GARAGFJSHED ❑ WINDOWS O BASEMENT FIHISH ❑ ROOF O DRAIN TILE ❑ DECK ❑ SIDING O OTHER ❑ SWIMMING POOL TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ADDITION ❑ MAINTENANCE/REPAIR ODELING DESCRIBE WORK BIING DONE: � Yl l O�' SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT ROOFING ❑ HOUSE ONLY gpSEMINT REMODELING SUBMIT: NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Ptan GARA.GES ❑ ATTACHED GARAGE 2. Proposed floor plan PROPOSED SIZE: 0 DETACHED GARAGE 3. List of structural memberssobe used PROPOSED HEIGHT: . SIDING FOR NEW CONSTRUCTION INCLUDING DECKS, O Vitryl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS_ & PORCHES SUBMTT: 0 Aluminum ❑ Trim REMOVED? � YES � NO 1. Site Plan/Survey showing the existing spvctures ❑ Other ❑ Fascia and ProPosed PTOject. 2. Two setc of construction plans WINDOWS 3. Energy Calculations IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALLIE AND OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW. OPENING CHANGES 8c TYPE OF WIIVDOW TO BE INSTALLED NUMBER OF WINDOWS .u.l, rr.r.� t�tc� na�r,L vtv vA1.U�►11V1v, liv(:LUL11Vl� "1t1L�' (:V5"1' Vr' LABUIi A1Vll MATERIALS: (USING TH 1997 U.B.0 FEE SCHEDULE) 'OTAL JOB VALUATION S �C �� '� OCCUPANCY TYPE Permit Fee $ See Back Page for Fee Schedule Plan Review $ � a 65% of Building Permit Fee Fire Surcharge $ (� .001 times the total job valuation Surcharge $ .0005 x Permit Valuation Minimum or .50 License Surcharge $ $5.00 (State Licensed Residential Contractors) SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determinarion) Curb Cut Escrow $ ft+ 6 ft= ft x$25= $ Erosion Control S $450 Conservadon Plan Review Park Fee $ Fee Determined by Engineering Sewer Main Charge $ Agreement necessary O Non Necessary O Totxl Due $ D..31 Make checks uavable to: Citv of Fridlev Attsch Stioulation 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 ork is to start without a permit on site; that the work will be in accordance with the approved plan in the case of al o�k wh' h requi rev' and approval of pl�1�S j SIGNATURE OF.APPLIC�WT . � .^^ "SP- �' NAME /�1 �%� �� g t k � G DA� �a�o6/a `o /�� • ti�v . �, �i� BUILDING PERMIT APPLICANT: PROPERTY OWNER I, � k��i �� G , understand that the State of Minnesota re uires q that all residential 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 ofxeselling 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 , � is the only residential structure I have built or improved in the past 24 months. I also 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. §514.01. Furthermore, I acknowledge 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 Sta.te of Minnesota.. I understand that unlicensed residential contracting, xemodeling, 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 and/or 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 a11 applicable building codes and city ordinances with the work being prefo ed on this property. f.,!,i ,� '�%i'7 � �-- _, ` /�,� � Signature of Prop�y Owner Date For questions or information on contractor licensing, or to check the licensing status and enforcement history of a particulaz contractor, call the Minnesota Department of Labor and Industry, Construction Codes and Licensing Division, at (651) 284-5069. The web site is: http://www.dli.mn.gov/Ccld.asQ �°'1-� �' �: �,.,.,.�, � � t .� �.. �c�;%�--� e�� : �� " {�w �� xi � ��` ° i' �'.'•y' , '�^ b-� ////�/� �� u� �'�6�3�''��'6�-��if''�- / �� .�� `,�.... 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