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�/LD/2011 wED 15: 15 FAx 555 5555 Timberline Roofing f�001/0p1 ` � . i, �� City of Qrono I Building Permit Application for Maintenance / Renovation ' (windows, doors, sidin , re-roof, etc.) —� Mailing Address: Permlt number: �� `� ' G f' � �.¢,0,�. PO Box BB �— ,ys,tal�ay.,�A�L5fi3 Jat `� � � a� � Street Address: Recelved py: 2760 Kelley Parkway Plan revlew fee; �� Orono, MN 55356 —�— Total Fee; � Maln: 852-249-4600 Fax� 952-249-4616 �vyyw.ci.orono.mn.us Thls application form rnust be cvmpleted in full and all required information must be submitted. i Incompleta applicatlons wlll be returned. (Please print) GENERAL INFORMATION: Job Slte Address; 3(I s SUSsG4� �. Will thia be a Parade of Homes,Remodelers Showcase Home or other I]lapley Nome7 ❑Yea o Il yea,e apeclel evanf permlf Is raqulred wlth PONce Oeparfinent and City Councll approvel 60 daye prlor to fhe evenf, Shutfle bue seivlce w1U be reQuired un�eaa applicanf demonslrates su�licienf an-site parkrng is evaileble, Non•permifted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: ►vame: 'h v,��n � �' rn � Stete License# Zb6 312 4�( Explration D�te: 3� 2G/2 Lead Certification Number: Explratfon Date: (f�or work on homes that were cons�ructed prlor to 1978 Phone: SZ.q'�- ia�d (offlce) (ps�' 33�-r8�1g (cell) Mailing Address: so51 Lf� hav 7 Clty: I lA AI�S ZIP: Ss�//� Cohtact Petson: f RG�j b AppliQant is: ont acto Homeowner �ci►�i.o�B� Emall andlor Fax: YYe,�db�y � qlr1.�' , �or'►'1 PROPERTY OWNER INFORMATION: Name: OG��orL Phone(day); ,S� — ��' SS�5 Address; �1l S SuSSrik �� City: rona ZIP: �� ,3560 Email andlor Fax PROJECT INFaRMATION: Type of Pro�ect; Any earth movement may requlr� ❑Door(s) ❑ Remodel ❑Flre Demage MCWD revlew 8 permlts: Mlnneheha Creek Welershed Dlstrict(MCW�) ❑Re-roof,esphelt ❑Repelr ❑ Storm Damege 18202 Minnelonka Blvd �Re-roof,cedar ❑ Restaratlon ❑W�ter Damage Deephaven,MN 55381 Phone; 952-�171-0590 [J Re-roof,other(apaclfy) ❑ Slding ❑Other: (speclt'y) Fax: 952-471-0682 __ ❑Windaw(s) _______ W�.minnehahacreek.or� Overell ProJect bescrlptlon: Eatlmated Constructlon Valuatlon of ProJect(exeludln land) $ APPLICANT ACKNOWLEDGEMENT: . Agrees to provide ell informetion required or requested by the Bullding Deparlment; • Cerll(les that ihe Informatlon supplied is lrue and correct to ihe best of his/her knowladge, The applicent recognizes thet thay � a�e solely respona�ble for submitling a complele applloalion being awere that upon fallure�o do eo, 1he atefi hae no alternetive bul to reJect It untll It le complete; ' . • Some or oll of the Informatlon that you are esked to provlde on thls appllcadon Is classNled by State lew es elther prlvate or confldentlal. Private data Is informatlon which generally cannot be glven io the publlc but can be glven to the subJect of the data. Confldentlal dala le Informatlon whtch generally cannok be glven to elther the publlc or the subJect of the data. Our purpose end Intended use of ih{s Informetlon Is to annuelly update our records and records of olher governmental agencles re uired b 18w. If ou refuse to su I tha infor ation the a lication ma nol be issued. Applicant's 5lgneture; Date: �� U� (� �Bac updeted� oe-oe-2o��