P - 45222Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /Cy"� / / � l l
SITE ADDRESS F
—.�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
G-d C (.�_ �' �'–.
Permit No.:�� � ��%�
Received By: g�ti�
Dat d�� ^, P' f�-I.-'�
YOUR E-MAIL ADDRESS .� j(/� ,�,isy,��y7 C� L['u� ;�.r,'r�
❑ OWNER �dCONTRACTOR
ADDRESS: ,S �l`7� C�%-'-i-z�-�'•� GTY �hlGf"'�l.=�' STATE I/�/I�ZIP
PHONE: � /� (,� ��i % 7G 5
CONTRACTOR NAME: -. �� �/(,y,y.�� �ai�ey-
SUBMIT A COPY OF STATE LICENSE #`�C>ts�c� -
YOUR STATE LICENSE �`f'�S LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: a� �'� �� �' � l��-= -C CITY��-cct%r> ��v� STAT��ZIP �`j cJ�
INSURANCE PHONE �loZ�l�.� 2 `T` FAX %G� �� �"' %`7 � '� G; '°7 �j'
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE � �vr �
❑ TWO FAMILY/NEW CONSTRUCTION STORIES %
PERMIT TYPE
TYPE OF WORK:
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
17 GARAGE/SHED ❑ W[NDOWS
❑ ROOF ❑ DRAIN TILE
�SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
DESCRIBE WORK BEING DONE: /�� 5�����
SIZE OF IMPROVEMENT LENGTH � WIDTH �� HEIGHT /� � SQ FT ��,
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBM]T:
NUMBER OF SQUARES ❑ HOUSE & GARAGE I. 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
Vinyl
❑ Aluminum
❑ Other
IWINDOWS
, IN EXISTING OPENINGS ❑Yes ❑No
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
FOR N�W CONSTRUCT[ON INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE ST(CKER ON WINDOW.
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)
TOTAL JOB VALUATION $ 38'G�. - 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
$ �'� � L� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ 3 .00] times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ �b $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �, Make checks payable 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 acknowtedge that the information above is complete and accurate; that the work wiil 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 will be in accordance with the
approved plan in the case o w which requires review and approval of pla s.
SIGNATURE OF APPLICANT��i���� PRINT NAME �v� �/l ���'� DATE /U—/�—��
APPROVAL INSPECTOR S[GA�TURE
Fonn npprovea o�te nw. 2o�am sa �rss �or�v� �
A p/�
��`/ E('"J''1 APPLICAiION FOR FIRMS
U.S. ENVIRONMENTAL PR07ECTION AGENCY TO CONDUCT LEAD-BASED PAINT ACTMTiES AND/OR RENOVATIONS
lmportaM: This apptication is required by 40 CFR §745.89(a} for renovations and is a substitute fw the letter required by
§745.226{fx2) for abatement. ConsuR the instrucfions for firrns applyir�g fior cefific�tion to asndud iead-based activifies or renovations.
For abatement activities, persons seeking individual certificafion shouid use U�e Appl �ication for individuals instead of this form. Please
flll out all sectlons. Type or p�int r�espans� in Mack or blue ink only.
A. Application Type (select only one box from Qptlon 1, 2, 3 or 4 of Section A)
1. � Opfron 1; Renovation Repair and Paintinn iRRP and Qust Samaina Technicianl Firm Certification
2.
4.
or
Initia!
Q or
and Painting Firm Certification
Reoertification
� Abatement Firtn Certification (5650 for first jurisdiction and
=35 for each additional jurisdiction — list jurisdiction(s) below)
{ni6ai Reoertification
� or �
List abateme�t jurisdicaon(s):
Combination Abatement/RRP FiRn Certification (5550
for RRP and one abatert�ent jurisdiction, t35 for each
addiiionai abaternent jurisdiction — tist abatement jurisdiction(s} below)
1) (5550) 2) (�85) 3) (5620)
(Please note, if applying for more than three jurisdictio�s add an additional $35 for each jur�didion and list them on a
separate sheet o# paper)
Option 3: Amend Existina C�tification
� Update firm information (no fee required)
Q Add abatement jurisdiction ($35 per abateme�rt jurisdictfon)
List abatement jurisdicfion{s) being added to your existing certification:
1) ($35) 2) {$70) 3) ($105)
4: Re�laoe Ceitificate
Replaoe Certificate (S7$)
s. ereter �ota� applicafion �See s�3c�C`i, vE'
Note 1: See instructions for additional tee information and examples of required fees.
Note 2: If you are a federally neoognized Ir�ian Tribe seelcing oertificatian as a firm chedc yss in the ques6on below and see fees
Schedule in the instructions to determine %e �uired.
Yes � Mo �{ndicate whether you are a federally-reoognized Ir�dian tribe seetcing oertification as a firm.
C. Applkarrt hrformation
Na� of Firtn: ..� vc ;- !l/t ��.� r�{v�H � 7
�
s��a���: a77Y /��T /�.�.t... t����..�� iv�N ss3n°f
Street Addr+ess, Suite Phhsnnbar (PI8a8e rW P.Q. Box) City Sfate Zip COde
Mailing A�ress:
(d diRererrt from above) Str�eet Address, St�e Number City State Zip Code
Narr�e ofAtte�ng Individusl: � �/-«" � v:i��� �
Last First Middle
Fi►m's Phone #: ?(r ; 7� 3:� / 1 Y ext #: Attesting Individual's Phone #: fa i 1��� 7 4 7�r ext.
Attesting Individuai's E-mailAddr�s: .� M li,:kei� � t��e., c,��
�A r-om, e5oarr t�++�+») Paoe � a z
Fortn Approved OMB Mo. 20700155 E�irea 10/3V71
D. Website Listing
Once certified your firm will f�e iisted on EPA's web based search tool. Ptease select tlte type ot' servicels) your firm will
provide:
Renovation ❑ Evaluation ❑ Lead Abatement
E. Lead-Based Paint Activity or Renovation Violation[sj
Dces the firm have any past, present, or pending tead-based paint v'rolations ot EPA, Yes a No �
State, U.S. tenitory, or Indian tribat iand(s) r�egulations? i# yes, piease attach a written expianation.
F Certification Stateme�rt
1 hereby attest and affirm tt�e following:
• The information induded on this application, induding any attachments, is true and acxurate to the best of my belief and
knowledge.
• 'fhis firm shali only employ appropriately qualifisd individuais to conduct tead-based paint aetivities and renovations.
• This firm and its employees shall foliow the woric prac�ic:e standards set forth in 40 CFR § 745.227 for conducting iead-base�i
paint �tivities or 4Q CFR § 745.85 for conducting renovations at all times.
• I adcnowledge that any certification issued pursuant to this applicafion, induding any attachmeMs, will be subject to revocation
if issuance was based on incorred or inadequate infrnmation that materially affected the decision to issue the certification.
�`.e' �u�.`'--` Gev�f;� f�-� 2�-.1,�����-��^ /t� ���1 ll
Attesting IndividuaPs Signature Trtle Qate Signed
(Please sign legibly within the boundaries of the baa above.)
Privaqt Act SYatemeM: This �rtbnt ia provided pursuant to the P�Svacy Ad of 1974, 5 U.S.C. §552a. The aulhority fo► odlectirq 1t�e informati0n is 40
C.F.R. Part 745. �d 15 U.S.C. §§2882 arW 2684. The infortnatbn cdlectad w� this form wiB be used m e�abNah tlx apPNc�'$ �ibifi►Y Tor ce�tif�ion to
conduQ lead-based Pefrd activities and renovations i� target housin9 arxi chifd-oocuP� fac��ies. Diadosum dthis iMotn+stian is wlwtlary; however. the
talure Eo povide this irdormebon +neY deieY ar prevent � appGcanYs �n. 71tis iMonnation maY ba �sdoaed in appropriste �d 6mited arcaxr�atarroes
to: EPA employees, coMrecioB. 9�� or afihera wlten perfortning dWes thet are compatlde with the putpoae for which tlbs iniorfttetiotl is odl�ed ard
w�n this infonnatiai is nacessary to compkte the task; a member o( Conpress in reaponx to a req�st mede wrth your owm� and on yow beh�F:10
appr�riele taw e�NOrcerr�errt agendes responsibk for invesb9��9, ��+ry9, P�d�9 a�P����9 �� stattdes. cales or reg�dat+ons �d ttus
itdorrr�on +s relevartt to d�+at +eePor�+blHtY: � aPP►pP�e �1�� �Y vW� s�tt �ado�ure is compatlDle with the piapoee fer wrtvch this ir�fo�melion
is ooMMecxed arM Uie EPA or ihe United Ststes has � interest in the Proeee�nD; and tl�a DepartmerM d the Tneaeury. the Gene�al Services Admini�, the
General Aocourtting Office �d ott� Federal, State, and Loc� Agencles for autha¢ed activit� r�ed to this iMormation.
Before you mail your applicatlon and certtlication fee, make sure that you have:
• F+Iled out all applicable sections of the application
• Signed and dated the application
• Made a copy of your application for your 61es
• Endosed the appropriafie certification fees (chedc or money order)
• Make chedc payable to U.S. EPA
• Prir�bed "Lead Program UserFess'on the chedc or rrwney order
• For mare informaation, see the fees sedion of the insductions
Mail briginal canpisted application, wppiorting ma�sriats, and tl�e certi(icafbn fee bo:
U.S. EPA
Lead User F�s
P.O. Bwc 979072
St. Lauis, MO 63197 9000
EPA Fam 850a27 (Rev 9/11) aaae s a z
� ; � ��� �n� �.�����F�x��� � �..�:�=a���.,�<,��;,�� ���������..rc , __
8375
JOE MEYER HOMES
2774167TH LN NW
ANDOVER, MN 55304-2070
17-2-910
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i+'008375�i' �:09L000022�: i96686505ii'
' 1�QNIVE${}TA1]&PARTMf_N7�if" ��. -� ��'S����ITIAL BLDG CONTRACT�R � �
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L.�ABOR & 1NDUSTF�'Y
Construction Codes and Lice�sing pfvision _ Licensing and Certification Services 443 Lafaye[te Road N St. Paui, MN 55155
Websiie: wvuw.dii.mn.aov/ccld.asQ Emaii: dli.iicenseCa)state.mn.us Phone: 651.284.5034
This is 2a Gertify That �he e�rtifica.te holder is licensed as a RESIDENTIAL BUILD�i'�tG G�l�'C'tZ�C7'QI� ia� the state of Minnesota and is in
co�4�iliance wi#I� Mi�nesoFa �tatutes 326B.805, and may build residential rea) estate, cQntract ar offer tv contraet with an owner to build
residential real estate; and cantract or offer to contract with an owner to improve existing_ residential real estate; provided the
responsible individual is at alt times a QUALIFYING BUILDER and the certifreate holder inaintains'cnmpliance with the required generai
liabiiity insurance, and workers' compensation laws.
License ; RESIDEN"�lAL BLQG �ONtiRACT4R
Lic Number : BC602845 , �OE'MEYER.HUMES {NC
Effective Date : 2774 1 �?iH �Rl
Expiration Date : 03/31/2012 ANDOVER, MN 55304
V�RtFY t1R,-'�£i-�3J4Tf STATUS, BOND, AND INSURANCE INFO Ai www dtE mn.�ovtccldlLi�Verifv.ast� (ENTER NUMBER).
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