P - 84363Building BUILDING Perrnit No.: �I? � ( `I�.�
Inspections RESIDENTIAL APPLICATION Recei�ect By:
763-572-3604 CITY OF FRIDLEY ��e�����
763-502- 977 FAX EFFECTTVE i-i-zo�2
DATE �� � ! 2- YOUR E-MAIL ADDRESS
SITE ADDRESS I i�4 D (�� } j �(?� ,rJ -� �i G.
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: J�_ N•i 2_
TENANT ADDRESS: CITY STATE Z1P
PHONE:
CONTRACTOR NAME: . � � �? Z �_--*�
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTIFICATE OF ADDRESS: � D� I,�CtN`Qv�L G � �--�% CITY ✓''�� ,'1, L STATE fh ZIP �,�� %
INSURANCE PHONE / 2 ��/ '�7 � Z FAX
PROPERTY TYPE �SINGLE AMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION � ADDITION ,/
❑ MAINTENANCE/REPAIR ❑ REMODELING ��t� O C � S S � � ^C�D UJ � '1 � �'�
DESCRIBE WORK BEING DONE: ��`n0 V Q,- S+`��1`� tV �'� � t'� C'` C C 11 0'� `� N Q�J U f C'I�ZS �"^ U�'�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSB & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARt1GE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO �• Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS�IYes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF B�nSQ �'� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �(�' -(
TYPE OF WINDOW TO BE INSTALLED C��"P LS NUMBER OF WINDOWS ..L�
ALL FEES ARE BASED ON ALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALiJATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� O�(U�1G THE 1997 U.B.0 FEE SCHEDULE)
I OCCUPANCY TYPE
$ , �`� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ `a t7� .001 times the total job valuation
$ C� .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 Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ i� Make checks pavable to: Citv of FridleY Attach
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 oniy an application for a permit an ork is not o start ithout a permit on site; that the work will be in ccor ance with the
approved plan in the case of all k whi ' e iew nd app val of plan { ��j � I_. � p � �
SIGNATURE OF APPLICANT � P T NAME � E' � �� �A o� DATE
APPROVAL INSPECTOR SIGNATURE
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N�Q'#'iFY TH� D�P�►RiMEN7 OF A CHANGE IN YOUR BU$INESS.
Faiture to dQ sa, sub)�ects you to administra#ive penalties<:�t up,to $'10,0�#0.
15-Day Nctice Requirement— Forms available online at www.dli,mn.aov/CCLD/LicUodBte.asn
• Change in business' physical adtlr�ss, rtt�(fing address, pY�one number, or emaii address
• Change in control, owners; officers; d�rsctors, members, partners
• Change i� business' legal ►larrt� and��r �ssumed name
. toss of or change in G�UALIFYING BUlIDER
• Cha►tge in general li'ability insurance or workers' compensativn insurance coverage
irrimediaie Notice Reqair�rnent — Notification to QLI in writing >
w ;�udg�+tQnt Qebtcar. ;A licensed contractor has 15 days to provide writfen �totice of tMe finding that it is found to be a judgment
debtor based upon conduc# requiring licensure.
• Bankruptcv Petition Filetl. A liceitsed contr��tpr: has 15 days to provide written notice that it filed a�etition fpr b.artkrupl�y.
• Conviction Notice. A tice��tsetl �ontractar has ifl d�ys to provide written notice thai it has been [t�und guiity of a felony, gross
misdemeanor, miscfeme�nor or =ar�y ct>t�nparable 4ffense related to the license, including convictions Q# <#r�ud,
misrepresentatian, misuse of f�rsds; theft, criminal se�ual conduct, assault, burglary, conversion`o# tunds, ar theft of proceeds
in this or arty other state or any other United States jurisdiction.
YQI�R C�Ri'I�I�A'�� 1� BE�,OW THE PERFORATION. �HO�N C�Ri1�ICATE 6VHEN OBTAINING PERMITS.
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ConsmicUon Codes
Website: w �i
BLDG CONTRACT�#i �
and CerUfication Services 443 LaFayette Avad N 5t. f?aut, MN 55155
d1f.Ncenseidstate.mn.us Pho�e: 651.2@�4;5034
This-is to certify that the certificats hdlder is licensed as a RESIDENTIAL BUILD.ING CQNTRACT�R in the state of Minnesota and is in
corttpliutace witU Iv(itftiesota Si�tutes 326B.805, and may build residential re�l estat�, conh�ct or offer to c.sr�itra�t witit an owner to build
residential real cstatc, and ce�s�i�act or of%r ko conttact with an owner to improve existing resic�ential tcaal. esfate; pra�rided the
responsiliie in��vidual is at �1� rimes a QUALIFYING BUiLDER and the certif��ate hotder;maintains compliance v�+ith the required general
liability insurance, and workers' compensation laws.
License : RE$ID�NTIAL BL�� G41�t'iRACT�R `
Lic Number : BC3508i8 `BENO� ENTEf�#'AtSE tf�tC
Effect�v� Date : 04/01/201� g�� L.Afi�EW�1QD LN o
Expiration Oate : 03/3i/2014 °' pLYMOUTH; MN 55447
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Y�A1FYt�p-`TE�DAtE STATUS, BOND, AC�D INSURANCE INFO ATwww.dli.tlt�.aQvlc�fdfLiG�ferif�,asp (ENTER NUMBER).
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F«m n�po,rea a�e Ho. 2o�ao�ss �res �ar�v»
�/E� APPLICATION FOR FIRMS
U.S. ENVIRONMENTAL PROTECTION AGENGY TO CONDUCT LEAD-BASED PAINT ACTMTIE3 AND/OR RENOVATIONS
Importa� This application is required by 40 CFR §745.89(a) for renovabons and is a substitute for the letter requir� by
§745.226(�(2) for abatement. Consuit the instrudions for firms applying %r certification ta arnduct lead-based acaviti� or renovations.
For abatement activities, persons seeking individual cerfifification shoutd use the Appticatiort for Indh�iduals instead of this form. Please
fili out all sections. Type or pri� responses in bfack or blue ink only.
A. Application Type (select only one box from Option 1, 2, 3 or 4 of Section A)
1. � Option 1: Renovation. Reaair, and Painting (RRP and Dust Samplina Techniaan) Fum Certification
or
2. I ORtion 2:
initial
Qor
Renovati�, Repair and Pair�ting Firm Certification
Recertfication
Q Abateme� Finn Certification (5550 for flrst jurisdiction and
$35 for each additionai jurisdiction — fist jurisdiction(s) below)
Initial Recertification
Qor Q
List abatemeM jurisdidion(s):
Combination AbatemeM/RRP Firm Certification (5550
for RRP and one ababement jurisdiction, S35 for each
additionai abatemerrt jurisdiction — list aba�merrt juriadiction(s) below)
� ) (Ssso) 2) fSsss) s) (Ss2o)
(Please note, if apptying for more than three jurisdictions add an addfional $35 for each jurisdidion and list them on a
separate sheet of paper)
3. I Op��'On 3: Amend Existina Certification
Update fiRn ir�famation (no fee requirred)
Q Add abatement jurisdiction (S35 per abatement jurisdiction)
List abatement jurisdicfion(s) being added to your existing certification:
1) ($35) 2) i$70) 3) ($105)
4. Option 4: Reolace Certificate
� Repiace Certificate ($1 v�
B. Errter tatal appiication fee $ Q t% �-"'
Note 1: See instruc#ions for additional fee information and e�mples of required fee,s_
Note 2: If you are a federaliy reoognized Indian Tribe seeking cert�cation as a firm check yes in the question be�w and see Fees
Schedule in the i st "ons to determine fee r�uired.
Yes Q No Indicate whether you are a federally-recognized fndian tribe seeking certification as a firm.
C. Applicant Ir�formafion
Name of Firm:
Business Address:
� � f�b/�?
; 0 5 t, �-rv � 1� Oo � �.
Street Address, Suite Number (P�ase no P.O. Box)
z,,...
.L r'1� �,
P �,��►�u i �1
City
M � 55�f �
State Zip
Maiiing Address:
(if differerrt from above) Street Address, Suite Number City State Tp Code
Name of Attesting IndividuaL• tT" � � ( �"i � �. � � ,..� �'� I �
last First Middte
Finn's Phone #:( � �� �� ��� � ext #: Attesting IndividuaPs Phone ��lZ �� M��?�xt.
�
Attesting IndividuaPs E-mailAddress: a k�� �� � �l v�+��
EPA Famt 8500-27 (Rev 9/11) Page 1 Of 2
�
Fomt Appreved OMB No. 2(T70.p155 E�ies 10/31/11
Once certified your firm will be listed an EPA's web based searct� tooi. Please select the type of service(s} your firm will
provide:
� Renovation ❑ Evaluation ❑ Lead Abatement
E. Lead-Based Paint Activity or Renovation Vio{ation[s]
Does the firm have any past, preserrt, or pending lead-based paint violations of EPA,
State, U.S. territory, or Indian fibal iand(s) regulations? If yes, please attach a written explanation.
F. Cert'rfication Statement
Yes O No Q
i hereby attest and affirm the foliowing:
• The infortnation induded on this application, induding any attachments, is true and accurate to the best of my belief and
knowledge.
• This firm shall only employ appropriately qualified individuais to conduct lead-based paiM ac�ivities and renovations.
• This finn and its employees shali follow the Hrc�rlc prac6ce standards set forth in 40 CFR § 745.227 for conducting lead-based
�irrt activities or 40 CFR § 745.85 for canducting renovations at all times.
• I adcnowledge that any certification issued pursuant to this application, induding any attachments, will be subject to revocation
if issuance was based on incorrect or inadequate information that materially affected the deasion to issue the certification.
Attesting
(Please sign legibly within the
of the box above.)
� _
� �v-e� ( i�r� ac� e Q ( � � t �
le Date SiAi
�cy Aa sta�em�,t rn�s sra�emeM �s pro�aea po�su�t ro me �cy na o� � s�a, 5 U.S.C. §552a. llte aufhaity for cwlleding tllis ir►formafion is 40
C.F.R. Part 745, and 15 U.S.C. §§2&82 and 2684. The ir�fortnation oollected on this fonn will be used m estaWish U�e ap�icaM's eligibiGty for cer6fication to
aondud lead-based paiM acxivities arM renovaiions in target housing and child-occupied faaNBes. Disdosure of this infortnation is voluratary; however, the
failure to provide this iMortnatiwi may delay or preverrt an applicar►Ys certificat�n. This infomiation may be disclosed in appropriate and limited circurnstances
to: EPA emPbqees. ow�tractors, grantees or ahers when performing du6es that are compatible with the purpose f�a' whidt this ir�forntetion is ColleCted and
when this iMormation is neoessary to cbmplete the t�Ic; a rt�mber of Congress in response to a tequest made with your cor�t ar►d on yout behalf; to
aPProPriate law enforcemeM agencies responsible for investigatin9. enforoing. prosecuting or imptemeMing specific statutes, codes or regulaUais and fhis
information is rele+raM to ihat responsibiliry; an appropriate �fjudicatiNwe body when such disdosure is compatible with the purpose far which this iMortnation
is coltected and the EPA or the United States has an ir►terest in ihe proceeding; and ihe Departrnent of the T�sury. U�e General Serv�es At�ninishaGon, tfie
General Accrounting Oifioe and ofh� Federal. State. and Local Agencies for authorized acdvities related to this irvformatmn.
Before you mail your application and certification fee, make sure #�at you have:
• Filled out all applicable sections of the application
• Signed and dated the application
• Made a copy of your application for your files
• Endosed the appropriate certification fees (chedc or money order)
• Make check payable to U.S. EPA
• Prirrted "Lead Program User Fees" on #he chedc or money order
• For more iriformation, see the fees sedion of the instructions
Mail o�iginal completed appiication, supportlng materials, and the certification f�e to:
U.S. EPA
Lead User Fees
P.O. 8ox 979072
St. Louis, MO 63197-9000
EPA FOmt 8500-27 (Rev 9171) pa� 2 pf 2
BENOZ HOMES INC -
6� LANEWOOU LN N
PLYMOUTH, MN: 55447
PAY TO THE
ORDER OF-
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