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VIA ' RP—
tht'th S ttB of M1leSptB T!eq[iFeS.
that zesdentt`a f ,
o (xtrs,rcznodelers and roofers obtain a stat
aE e Iac+ftase
1fY for sp ifi pdo firom the h9e
g recluzrer#iextts. T IZeaGse regv tnent applies tQ own"S ofremd ai a whfl bUiid or improve such
y for PUTPoses of spPula�ian`or res ie:
13Y signiing this document, I attest to the fact that I am impmving this house for my own
use and am not building or impxvvng this hawse for the
claim W be exempt from the state licensingrequirementspurpose of reselling it_I hereby
of building or remodeling on speculation or for resale a d that th e fo because I am not r IwI�zch I the mess
applying for this permit, located at rb q I am
is the only residential structure I have built or imVrov in the past 24 months, I also
acknowledge that because I do not have a state license, I forfeit any mechanic's Iien
rights to which I may Otherwise have been entitled under Minn. Stat. §514.01.
Furthermore;I aclmawle40 that maybe hiring:ind endent contractorscertain to perform
aspects Of the construction or mVrovement of l! house and I understand that;
some of these contractors may be required to be licensed by the State of Minnesota:;I understwd-tom teed residential contracting remodeling,ng, and/or�covfing activity IS a
I °r of der : �` ..�32 082,stzbd: I6 and can atsa�resuit in a fine of ter to
fia*er state that I uhdott that thefiling.of a false statement with.
The'` - o#'F>rfdl z>Rtia. aIsc�result in '
Y cximinal prosecution and/or civil penalties
to applicable city ordinances and/or.state statutes;
l have also:been hiformed and acknowled
.ems - by listing myself as the coutractor'for
Pm3 Y..alvr�e vl .responsible toe,CI of�rrdi foi compliance will
all applicabic builclg.icades ariri city. ordnatzees
PropertY being preformed on this
Sign Lure f ape Owner
Date
For questions or information on contractor licensing,or to check the licensing status and enforcement
history of a particular contractor, call the Minnesota Department of Labor and Industry, Construction
Codes and Licensing Division, at(65 i)284-5069-The web site is: h :/l vw.wjI-; ty. yE c..