2011-01543 - roofing - Laserfiche WebLink

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�'R.F _ �_ - �i�y► �f O�-��o ,,: ��; � �,t: ��. � ' �uif�iing Permit �ppii�a�Eior� for IV�ainte�an�e / Re�o�a�ion � � (window�, doors, siding, re-roof, etc.) Mailing Address: �' /�,L+o,� PO Box 66 Permit number: � —Q� J �" �� Q Crystal Bay, MN 55323-0066 Date received: / /� � a ��_� ,a '��i� s, � Street Address: � Received by�: t. ��n �� ,� 2750 Kelley Parkway � Pian review fee: �� kEsxo4`�� Orono, MN 55356 '' Total Fee: L% � / Main: 552-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �� , This appfication form must be completed in full and all required information must be submitted. >�; Incomplete applications will be returned. (Please print) `' � GENERAL INFORMATION: �r� �`�� Job Site Add�ress: .� � �`'�? �C"z�� G�,�/� � <� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No r;, If yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus servrce wil/be ; required unless applicant demonstrates sufiicient on-site parking is available. Non-permitted events wil/nof be allowed. � �� CONTRACTOR/APPLICANT INFORMATIO�l: ,� �� =4 Name: �� • p i�r/G --�tJ�, R:a � . State License# �C � ��7 -� Expiration Date: Q - �� Z � 3 � Lead Certification Number. �_ Ex iration Date: �j�Zy�ZO/ �� � /1/QT �/�Z�i —/ P �_�_� � (for work on homes that were consfructed prior to 1978 Phone: 'J�SZ '�Z�-- �/y/ (office) �/L—Z7�— 2�1 y� (cell) �, Maifing Address: Z p � - vC City: _ y� ZIP; S—��Zy ,�' Contact Person: �/C—�� 'O�T� Appficant is: ontractor / Homeowner (Circle One) F : Email and/or Fax: �` ;<a ��' PROPERTY OWNER INFORMATION: {„ �„' Name: %j 2-� L/.1i2�Zvl! �x � , €:: Phone (day): GISZ—L/�b3_/,�5�7 � ? � �� Address: Z� �"G� f�v,�1rS� 2.� �= City:/�ti'c, G 11/1� ZIP: �S 1��' �:3 Email and/or Fax � �, . �k.�: �� PROJECT INFORMATION: �� rq Type of Project: Any earth movement may require A� ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: � Minnehaha Creek Watershed District(MCWD) �y �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Re-roof, cecEar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �' ❑ Re-roof, other(specify) ❑ Sidin Phone: 952-471-0590 � g ❑ Other: (specify) Fax: 952-471-0682 � ❑Window(s) www.minnehahacreek.orq " � s Overall Project Description: �'��7 �� CZUQ��L�,.(�l.�,G4'� ,�¢7� ,C�� ,�/�� Esfirnated Construction Valuation of Project(excfuding land) � `� �'2 4 z�s o c� ,v . , � APPLICANT A�KNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; �:� • Certifies that the informafion suppfied is true and correct to the best of his/her knowfedge. The applicant recognizes that they � are solely responsibfe for submitfing a complete appfication being aware that upon failure to do so, the staff has no alternafive � but to reject it until it is complete; :� • Some or all of the informafion that you are asked to provide on this application is classified by State law as eitner private or � confidenfial. Private data is information which qenerally cannot be given to the public but can be given to the subject of the �� data. Confidential data is information which generally cannot be given to either the pubfic or the subject of the data. Our �� purpose and intended use of this information is to annualfy update our records and records of other govemmental agencies ,;� _ re uired b taw. If vou refuse to sup I the information,the a licafion ma not be issued. ApplicanYs Signature: �_�� Qato: z _ `�� ,;;Y �b /� % Last Updated: 08-09-2011