2015-0457110/23/2015 12:52 FAX. 6126258408 UofNN Pharmacology IM 001 /001
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BUILDING PERMIT APPLICANT: PROPERTY OWNER
I, C!9%Zr�'( U� ���L-� �� understand that the State of Minnesota requires
that all residential building contractors, retnodelers and roofers obtain a Mate 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 1 ant improving this house for my ovm
use and am not building or improving this house for the purpose of reselling it. I hereby
claim to be exempt from the state licensing requirements because 1 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 �!%E.�S3�ZiX`e
is the only residential structure I have built or improved in the past 24 months. I 91so
acknowledge that hecause I do not have a state license, I forfeit any mechanic's lien
rights to which 1 may otherwise have been entitled under ;Minn. Slat. §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 State of Minnesota. I
understand that unlicensed residential contracting,, remodeling, and or rooting ati it is a
misdemeanor under Minn. Stat. §326B.092, 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 City of Fridley may also result in criminal prosecution andlior civil penalties
to applicable city ordinances andlor 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 Cite of Fridley for compliance will
all applicable building codes and city ordinances with the work bein..preformed on this
property. !�%
Signature of Property Oiwvher
Date
For questions or information on contractor licensing, or tc check die licensing status ane enforcer. ent
history of a particular contractor, call the Minnesota Department of Labor and Industry. Construedon
Codes and Licensing Division. at (65 11284-5069. T)e web site is: l�ttp"'�aw}l_dl .lnn�ovr'Ccld.asp