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.� City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Maung Address: Permit number. iD PO Box 66 O L Crystat Bay,MN 55323-0066 Date received: 11 1 Received by: A Street Address: 2750 Kelley Parkway Plan review fee: Orono,MN 55356 Total Fee: 76(to `7 s Main. 952-249-4600 Fax: 952-249-4616 o.vvrr.cLorong.mn.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: 645 Tonkawa Road Jab Site Address: Will this be a Parade of Homes,Remodelers Showcase Nome or other Display home? Yes No If yes,a special event permit is required with Police Department and Obt Council approval 60 days prior to the event shuttle bus service will be required unless applicant demonstrates suftent on-site parking is available. Non-permitted events will not be allowed CONTRACTOR f APPLICANT INFORMATION: Name: J Zac Inc. State License# 20593845 Expiration Date: 3-31-2012 Lead Certification Number. NAT 106196-1 Expiration Date: 3-16-2012 (for work on homes that ware constructed prior to 1978 238-4051 (cell) Phone: (763) 497-4444 (office) Jerrys-(763) Mailing Address: 5249 Ogren Avenue NE City:St.Michael ZIP:55376 Contact Person: Jerry Z a c hm a n Applicant is: Contractor / Homeowner (cirde one) Email and/or Fax: i erre i zacinc colli Fax – (763) 497-4454 PROPERTY OWNER INFORMATION: Name: Temple Israel and Myra Giesener Phone(day): ( 6.12) 377-8680 Address: —' l Emerson Avenue South City Minneapolis Z1P:55405 Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits: ❑ Doors) ❑Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) M Window(s) []Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven,MN 55391 Siding ❑Restoration ❑Other.(specify) Phone: 9521171-0590 Re-roofFax: 952-471-0682 ❑Fire Damage °4_�;r.minr;vha�:acreek.arg Overall Project Description: Repair & Reroof due to Hail and Storm dama Estimated Construction Valuation of Project(excluding land) . Btu APPLICANT ACKNOWLEDGEMENT: Agrees to provide all information required or requested by the Building Department; cuppiiad is trio 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 connaennai. Pnvate care is InrbrmaUOn 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 9ttqis information is to annually update our records and records of other governmental agencies required by law. If you refute to ly the i ion,the application may not be issued. Applicants Signature: Date: Last Updated: 03-01-2011