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- Nov.- 1. 2011 8; 56AM All Elements Inc. No. 6931 P. 2 City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc. Mailing Address. Permit number: CZ —� O�O O PO Box tib Crystal Bay,MN 55323-0066 pate received: Street Address: Received by. 2750 Kelley Parkway Plan review fee: Orono,MN 55356 Main, 952-24911600 Fax: 952.249.4616 www.d.orono.mn.us Total Fee: This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: 3765' o5n d ro-n4, {'�/i/ S•�35-E Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? ❑Yes ❑No try".a apeoW event perm#is required wRh Poke Department and Cry Coundl approver 60 days prior to the event. shuttle bus service w#I be required unless appikant denwestratss sutrklent on-site pedift is available. Non-pemr#led events w01 not be alkwxd. CONTRACTOR/APPLICANT INFORMATION: Name: l�f� 1 ne,)i-s �c. State License 0 13C 3 2 3 S VQ Expiration Date: 1- 31 - 291Z Lead Certification Number: Expiration Dale: (for work on homes that were constructed prior to 1910 Phone: 76 3 3/y• p 2.3 y (office) 7 6.3-2 o Z-6 3 y6 (cell) Mailing Address: 3 y7 nimd-a tfi,deCity: 40,1 t.cc/o ZIP: .55',762 Contact Person: J uzh,' .Sr1,-1l, Applicant is: ontractor / Homeowner (Circle One) Email and/or Fax: =ru�F��s�a ulteler,c�ts►�,c.net PROPERTY OWNER INFORMATION: Name: Bele HASst- Phone(day): q'5 3. - 1.5.1` 01 A 2 Address: 3765 Tope 2d. City. Orono AN ZIP: S,S 3 sd Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑Doods) ❑Remodel ❑Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) Re-roof,asphalt ❑Repair `A Storm Damage 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration C1 Water Damage Deephaven,MN 55391 Phone: 952.471-0590 Q Re-roof,other(specify) [3 Siding C3 Other(specify) Fax: 952.471.0682 ❑ www.minnehahacreek,ora Window(s) Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ 2731, 32- APPLICANT -73/, 32- 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 alternative but to reject it until It Is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. 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 govemmental agencies required by law. IF you refuse to supply the information,the application may not be issued. Applicant's Signature: Date: