P - 84362Buildiug BUILDING Permit No.: o�Q �d �
Inspections RESIDENTIAL APPLICATION Received By: � `
763-572-3604 CITY OF FRIDLEY n���:�� ������
763-502-4977 FAX EEFECTIVE 1-1-2012
DATE G/ Z� / YOUR �MAIL ADDRESS N D 4� / C�' L� U) ('. ^° °� S. � d;�-
SITE ADDRFSS .� �� !1 K� L %'' �Z � E•
TFIIS APPLICANT IS: O OWNER �CONTRACTOR
PROPERTY OWNER/ N�: �j E�/'� � H!4im J"��
TENANT nvn�ss: .5 N�� CrrY �-/2 f�(, � sTA�r�' � zir
PHONE: �� [, ' S`' I � � 6 � �
CONTRACTOR NAME: /� � � / i � � � �` �Y �- (,° ✓ j �� f' �, 4� ''•Y
SUBMIT A COPY OF STATE LICENSE �! Z D S j� Z I� LEAD CERT NUMBER �� �% EXP: I Z L� ��'
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �/ 3� N Lf � A% z 5 j T CITY M FG S STATE �'h�✓ ZIP -SS9%
INSURANCE PHONE I Z-. G, (J S" � 2 � 2 FAX I Z" L� �1 ` Z)
PROPERTY T'YPE .J�tSINGLE FAMII.Y/NEW CONSTRUCTION SIZE
❑ TWO FAMQ.Y/NEW CONSTRUCI'ION STORIES
PERMIT TYPE ��DITION 0 GARAGFJSHED ❑ WINDOWS
� BASEMENT FINISH 0 ROOF ❑ DRAIN T1LE
❑ DECK ❑ SIDING � OTEIER
❑ SWIbIl�IING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDTITON
� MAINfENANCFJREPAIR REMODELING -
DESCRIBE WORK BIING DONE: LS � c - M C �: / G1 � �, /�1 � ✓t IN+%i � r �1 �`C S S /n/ � '^ � �
` , r✓! i-- �_
SIZE OF IMPROVIIvIIIV'I' b" LINGTH WIDTI-I S HEIGHT S FT
R FIN O HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGB BASII�'NT REMODII.ING SUBMTI':
1. Existing Floor Plan
�ARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
3IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl OSoffit SIDING/SOFFIT/FASCIA �DITIONS_ & PORCHES SUBMTI':
❑ Aluminum ❑ Trim REMOVED? O YES ❑ NO 1. Site Plan/Survey showing the existing shvctures
❑ Otlier ❑ Fascia � PmP� P�.1�
2. Two sets of consUnction plans
WINDOWS �!' f l � h 1 � 3. Energy Calculations
IN EX[STING OPENINGS �Yes QNo LOCATION OF WiNDOWS /" 'O � FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACI'URE STICKER ON WINDOW.
OPENING CI IANGES & I
TYPE OF WINDOW TO BE INSTALLED C�t St' ✓� �°` NUMBER OP WINDOWS
a1.1. r��:�� � BAa�D uiv vALIJA�I�IUtV, iNLLUDiNV '1't1E c;US1' UF LA13UR ANll MATERIALS:
(USIN� THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �� J[.� . OCC[JPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
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 or .50
$5.00 (State Licensed Residential Contractors)
$2365 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Deteimined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridlev Attsch
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII, PROCESSED
I hereby apply for a building permit and I ac edge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes o e C of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit an w k is not to start without a permit on site; that the work will be in acc� dance with the
approved plan in the case of al rk w i review and appmval of plans. ,�/2.��.2
SIGNATURE OF APPLICANT PRINT NAME /% �/l E' � S 1 a�G �f t DATE
NOTE: SEPARATE PEI�fl'Y� 4iRE REOUIltED FOR PLUMBING. ELECTRICAL AND
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��� �, ` �y.��� ,,���� ��Frorrr 612 605 8213 Page: Z/3 Date: 10/24/2012 8:40:08 AM
. v.v�.. v�� vvv v� � v N.�
Forr� Approved Of�SB Ab 2074-01�. Expires tp131f'1
'��i%� APPlICAilt.lfV �OR f FR�VfS
U_5. ENV}RONMEMAL PRC7TEC`i�ON AG�NCY TO GONDUCT LEAD-BASED PAtNT ACTfVITIES ANDIQR RENOVA71pNS
Important: This application is �equired by 40 CFR �745:89(a) fior renovati�ns and is a substitute for the letter required by
§745.226(�(2) for abatement. Consult the instrudions Eor firms appiying �or eertifiea#ian to cxmduct lead-based activ�ies or renovations.
�or abate�nent activities, persons seeking individval oertification shvuld use fhe Appllcatlan for Individuals instead of this fnrm, P[ease
flll Qut �it sectforrs. Type or print responses in black or biue Ink only.
A. Applica�ion Type �seEect only one bnx from Option 1� 2, 3 or 4 of SectFon A)
2_
2:
Initia� RecertiFcatior�
� ar Q Abatement �irm Certification ($550 for �rst �uri�iction and
S35 €ar ea�h add�tional juri�diction — Eist jurisdictio�{sj below)
Inifial Recertification
� or �
List abaternerrt jurisdiction{s):
Combina#�on Abatem+e�rtlFtRP Firm Geriificatian (5550
for RR}� a�d one a6atemer�t juaisdic#ion, $35 for each
addifiona! abate�errt juris�fiction — list aba#emer�t jufiscBction�sj below)
1) (�550) 2} {b385� 3} ($6�Q)
{Piease note, if applylRg for rnore than tluee jurisdic#ions add an additional $35 for each jurisdiction and list them cx� a
separate sReet of paper)
3. Optio
�
�
4.
Amend �cistir�c� Certific�#ion
Upd�te firm ir#ffnrmativn {no fee requirad)
Add ab8iemerrt jurisdictian ($35 per abatement JuHsdietion)
List abatement jurisdietion(s} being added to your existing certification:
1}
' Optic�ti 4: ReDface GerfifiCate
� Replace CertiRr,ate ($15)
2) f$�0) 3) ($10�
F�7�
�
B. Ent�rtatal application fea $ �D
Note �: See instructions for addifional fee informatian ar�d examples of required fiees.
Note 2 If you are a federaliy re�ized Indi� Tribe seeking certification as a firm check yes in the question bebw and see Fees
Schedule in the insUudions to determ+ne fee required.
Yes � No � fne�ca6e whetiher you are a federally-�ecognized Indian tribe seeking certifisation as a firm.
C. App�catrt
htame af Firm: MD Repairs, LLC dba Hoe�se Doctors Handyman Service
eusinessaadress: 3'!39 NE Hayes Sf Minneapolis MN 55418
StrEet Acldress, Suite Numder (Please no P.O. Bo� City State .iap CoUe
Maiiing Address:
(rF differerrt from above) Sbeet Atldress. Suite Ntxnber Ciiy State �R Gode
Name ofAtEes�ng lndividual: S#O�Ckel aerek �n�it�
� ��t �na�e
Firm's Phone #: 612-6a5-821'2 ex# #: Attesting Indiv�dual's Phone � 612-226-8556 �
Attesting Individuat's E-mailAddress: hd4�1�h0US�dOCt01'�.�111
EPA Form 8500-27 (Rev 9l11) Page � af 2
�� �,,� ��,�,�M ,,�w�� ��From: 612 605 82`13 Page: 3/3 Da#e: 10/24/2012 8:40:09 AM
.,.., i ,. „ , � ,,..., ., �. � ... N ...
FO1nlApprovedONBNO.2078-6155�F�iros 10o31H1
Orica ce�� yvur firm w91t t� listed on EPA's web based search tooi. Please seiect the type of servir.e(s) ycur firm wili
provide;
R€�ovatit�n ❑ Evafuatior� ❑ Lead Abatement
E. Lead-Based PaEnt ActivHy or Renr�vation Violationjs)
Does the firm have any past, present, or pending 1ead-based paint violatians of EPA,
State, Ll.S. ferritory. ar lndian hibal land(s} regulat+vns? lf yes, ptease attactt a wtitten explanation.
F. Ce�tifrcatiorr Statement
Yes � No �
t hereb� attest and aff'irm tltiE foFtawing:
• The informatian inc[ucf�d on t#�is application, in�uding any aHachments, is true and accurate to the best af my belief and
knovwledge.
• This firm shatl anJp empiay appropriately quaiified individuais to oondud lead-based pai►rt activities ar�d r�enovations.
• This firm and its employees shall folksw the work prac6c� standards set forth in 40 GFl2 g 745.227 for canducting IeacJ-based
paint adivities or 40 C�'R F 745.85 fc�r oanduc4ng renovations at a0 times.
• I ackrwwledge thai any certi�catian issued pusuaM to this application, induding any attachments, will be subjec{ Oo revocation
if issuance was based on int�ect ar inadequate informadon that materially affected the decision to Fssue the aertific�tion.
(I�lease sign legibly within the boundaries of the box abave.)
PtiveGy Aci Statement ih3s �etement is providecf prnBUant to the Priraey Act of 18Z4, 5 U.S. C. §SS?a i'he au�cirily 1'or cole�Grg this into�tt+aUon is 40
C:F.R. Part 7d5, end 15 U.S.G. §§2682 and 268d. The i�arme6un coNeGed cn tlas for»2 wi11 be used Eo esfablish tl�e appNcanYs etigi4ily io� oerUFication to
oorxAwY lead-dased peirst eWvi�e,s and r+�t�ations in tmrg� tiousiiq antl chtld.aeeupied fadflies. L?isdoaure oTttils inkxmation is vdunt�y; howev�er, the
tailure to pravide tllis i�fcx�nalion mey deley or prevent an aPP�icenCs oeNficafion. This in[armaUOn rnay be d'�sdaesM in appropria�e and pmifed eke�mslanoes
to: EPA emPbYees. oortih•adors. 9raMees or 6Uiers when petfartninp tlutiea that ara oompat�Llewith the purpose Rxwhich �ie irrFor+r�etion is odlected and
when Ihls iidwmatio� is neoeasaryr tp �p� �� a�y� p� Congress in nesppnse tp a requo�t merk witR your consent and on your behalF, ko
appropiate law entonoemerit agencie,r responsibie for im�atipatir�g, entorcing, prose¢uting ar impleenen[ing sper.ificslahrta., codes a regubaoons mtd Wa
irrorn�aHon ls relevent 1n that nespms�bilriy; an appropriam adj�licative body when such disd+a�sus�e i� cor�aMbte wUh the pmrpose for which Ws infortnation
is mrectad and the EPA ar the U�i1�ed Stetes has an unerest h the pro�eerFng; and the oepartment of 1he T�ry, rie General Services RdminisYation, the
Genetal /Lt�oauMinp OHke and c�et Fedoral, S�ES. and Local Age�xaes Gx acdhaized �iivfies telaied tn tt� inbrtnaffen.
Before yau rs�ail your aippiEcation and certifEcativn fee, rrmake sure that you have:
• Filled out alE applicable sedions of tMe application
• Signed and dated thE apptication
• Made a copy oi your ap�lication for your fites
• �ndoseCf the appropriate �Rificativn fees (check or maney orderj
• Make chec� payaksle to u.S. EPA
• PriMed `Lead Pragram CJSer Fees" ai the check or rnaney orcter
• Far �nore infarmatian, see the fees sectbn of the instructians
lYlatl aEiginal con►pl�#ed applicat�ort, supporting maLer�als, and the cerbificaiion fee to:
U. S. EPA
lead iJser Fees
P.O, 6ox 979072
St. louis, MO 63197-SD00
EPA F'orrn 8500�27 QRer 9117) Page 2 W 2
��, �, ` ��,��M ,,���� ��From: 612 605 8213 Page: 1/3 Date: 10124J2012 8:40:07 AM , �
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MD REPAIRS, LLC 4�5$
DBA.HD�Ja� �C}CTflRS HANdYMAN SER�/�GE r
. .. 3138HAY�SSiREE7NE . �` t7-t/9to8578
, MSN�fEAP8U5.MN 55418 DATE � � �� ;�f � �D3145391
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