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BUILDING PEIZNIIT APPLICANT: pIZOPER.TY OyWj�\TER
I, G��-�12AeW (�S Ill, ` , understand that the State bf Minnesstate ota r Sees
that all residential building contractors, remodelers and rooters o
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 s'—ng thus 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 of reselling 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 7`5 2 7 A 4)lc S( �V
is the only residential structure I have built or improved u1 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 Linder 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 State of Minnesota. I
understand that unlicensed residential contracting, remodeling, 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 C;cty of Fridley 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 City of Fridley for compliance will
all applicable building codes and city ordinances with the work being preformed on this
property.
Signature of roperty Owner
zoz Z.
Date
For questions or information on contractor licensing, or to check the licensing
history Of Ft particular conti-a.ctoz., call the Minnesota Department the
Labor and status and enforcement
Codes and Licensinb Division, at(651) 2gr1_5069 The web site is: htt //���ti ;[ndustiy' Construction
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