P - 40865Building BUILDING Permit No.:� �� � �
Inspections RESIDENTIAL APPLICATION Re � ed B:`° L
763-572-3b04 CITY OF FRIDLEY Da t����'c�� ' 7�
763-502-4977 FAX EFFECTNE 1-1-2011
DATE 09/27/11 YouxE-MA,LaDDRESS action@actionroofing.net
siTE.aDDxESS 6520 Able St NE
THIS APPLICANT IS: ❑ OWNER �(ICONTRACTOR
PROPERTY OWNER/ NAME: Deanna Roth
TENANT ADDRESS: Sd1112 CITY STATE ZIP
PHONE: 763-432-2681
CONTRACTOR NAME: Action Roofing & Siding LLC
SUBMIT A COPY OF STATE LICENSE # 5421 LEAD CERT NUMBER NAT-109445-1
YOUR STATE LICENSE
arrD cERTiFicaTE oF nDDxESS: 1315 Southview Blvd cITY So. St. Paul sTaTE MNzrr 55075
�tvsuRArrcE rxorrE 651-457-2642 FAx 651-457-0351
PROPERTY TYPE I� SINGLE FAMILY/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
69 MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: TeaC-OFF clI1CI I'e-i00f j�ItCileCI aIICI fldt COOf Oil IlOUS2.
SIZ6 OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING � HOUSE ONLY
NUMBER OF SQUARES 17•5 ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of stnictural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
O Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia
and proposed project.
2. Two sets ofconstruction ptans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 8,600.00 OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �� (� See $ack Page for Fee Schedule
$ 65% of Building Permit Fee
$ �7 .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Q 2.l� Make checks pavable to: Citv of Fridlev Attach
THIS IS
I hereby apply for a building permit and
conformance with the ordinances and
permit but only an applicatio r a e I
approved plan in the case all wor whi
SIGNATURE OF APPLICANT
APPROVAL INSPECTOR SIGNATUR
APPLICATION FOR A PERMIT-NOT VALID UNTIL P fJCESSED
;knowledge that the information above ' omplete and accurate; that the work will be in
e i f Fridley and with �nnesota Construction Codes; that I understand this is not a
3 work i no without a permit on site; that the work will be in accordance with the
re ew and approval of plans. KUI't M21'I'eII DATE 09/28/11
PRINT NAME
PLEASE NOTE: SEPA E PERMITS ARE REQUIRED FOR PLLTMBING, ELECTRICAL AND MECHANICAL