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FRG; Garlock French Roofing 612-722-7129 (THU)MAR 21 2013 14 :18/ST. 14 :18/No, 6823051221 P 1 City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) O \ Mailinng ABddreSsBs. Permit number: rX13 Crystal Bay,MN 55323-0066 Date received: Street Address' Received by: 2750 Kelley Parkway Plan review f Orono,MN 55356 Total Fee: p�8 Main: 952-249-4600 Fax: 952-2494616 www.ci.orono.rnn.us / This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION, /oN „ 1 Job Site Address: -53F/ Will this be a Parade of Homes, Remodelers Showcase Hom6 or ot6br DIspI y Home? LJ Yes No /f yes,a Special event permit is nmquimd w$h ftioe Department and City Council approval 60 days prior to the event, Shuft bus sandca"I be reoulred unless applicant demonstrates suntient onsite parking is available. Non-perinkted events win not be allowed. CONTRACTOR I APPLICANT INFORMATION: Name: loce- e:,- State License# Expiration Date: Lead Certification Number. Expiration Date: (for work on homes that were cons"cC d prior to 1978 Phone: 7 4; (office) (cell) Mailing Address: 57rC' a ,s ZIP; r a Contact Person: Applicant is: Contract / Homeowner (cirao one) Email and/or Fax: PROPERTY OWNER INFO ON: Name: fN N Phone(day): / `/ ZIP: Address: City: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ©Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Re-roof,asphalt Q Repair Storm Damage 18202 Minnetonka Blvd 2rRe-roof,cedar ❑Restoration p water Damage Deephaven,MN 55391 Phone: 952-471-0590 ❑ Re-roof,other(specify) ❑Siding ❑Other:(specify) Fax: 952-47140682 [:1 Window(8) www.minnehahacreek.orn Overall Project Description: Estimated Construction Valuation of Project excluding land) t �' 0 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 altemaWe 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 governmental agencies r uired by law. If you refuse to supply the information,the application ma nit be issued. Applicant's Signature: �il�' Date: Last updated: 08.09-2011