2011-01040 - roofing - Laserfiche WebLink

Home Browse Search

City of Orono t 4 Building Permit Application for Maintenance / Renovation . {windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: O�,�,�.0 PO Box 66 Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: � 2750 Kelley Parkway Plan review fee: ��xo�.��' Orono, MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be retumed. (Please print) GENERAL INFORMATION: Job Site Address: /� dr-- Sylvb`s � �II this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes o lf yes,a specia!everrt permif is required with Police Departmerrt and Cily Council approva/60 days pria to the eve»t ShutHe bus service will be required uNess appNcarrt demonslrates sulficierrt on-site parkirtg is availab/e. Non-permitted ever►ts wiN not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: Gns-- � State License# ap��g��,p Expiration Date: 3 3� �oii Lead Certification Number: a. / -/y�ly- /O- O/o 3L Expiration Date: � joiS (for worK on homes thai were constructed prlor to 1978 Phone: 7�3� 7/) -,f'G�G (offi�) g31•3.�6�G2/� (cell) Mailing Address: G39� �/C" a��✓ CitY: Z�P� ss�o Contact Person: �� f- Appticant is: ontractor / Homeowner �CirckOne) Email andbr Fax: �o",. �/�f� ,(e�,,�,,�o�✓,c�s r•o�,o.c��,., PROPERTY OWNER INFORMATION: Name: C �,,,.iP,,-{- �/r� 1� Phone(day): 9,�rZ -�/73-�-833 Address: Gp S S��LS ,f�,� /L� City: ,ry�aL 60 ,�, ZIP: �3.3�4 Email and/or Fax �—� PROJECT INFORMATION: Type of Project: Any earth movement may requlre ❑Door(s) ❑Remodel ❑Fire Damage MCWD revfew 8�permits: Minnehaha Creek Watershed DisVict(MCWD) -roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreekor�a Overall Project Description: ,Q��o s� � ��g� Estimated Construcfion Valuation of Project(excluding land) E(o5vo'�O APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; . Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this apptication is classified by State law as either private or confidentiaf. Private data is information which generally 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 public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies re uired b law. If ou refuse to su I the infor lication ma not be issued. ApplicanYs Signature: �:-- "7`-- Date: �i Z zv �c Last Updated: 08-09-2011