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May. 5. 2009 8:51AM SELA ROOFING No, 6972 P. 2 <br /> City of Orono <br /> Building Permit Application <br /> Mailing Address: Permit number. C7 <br /> 04 OPO Box 66 <br /> Q Crystal Bay,MN 55323-0066 Date received: �a 9 <br /> a Street Address: <br /> Received <br /> 2750 Kelley Parkway Plan review fee: <br /> Orono,MN 55358 <br /> Total Fee; <br /> Main, 952-2494800 Fax: 952-249-4616 www.ci.orono.mmus <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: r <br /> Job Site Address: 645 �R�j <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes U No <br /> If yes,a special event permit is required wi7h Police Department and City Council approval 60 days prior to the event shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking Is aveifb/e. Non-permkted events will not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATION- <br /> Name: <br /> NFO ION:Name: Kj <br /> State License# Expiration Date; (.7 <br /> Phone: - office cell <br /> Mailing Address: C' ZIP; <br /> Contact Person: AJ Applicant is: ntra r / Homeowner (circi•one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone(day): — — <br /> Address: City: 6"71f-lo ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project Any earth movement may require <br /> MCVYD review 8 permits <br /> 0 Door(s) El Remodel L]Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> E3 Windows) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ®Siding 8 Restoration ❑Other.(specify) Phone: 952A71-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑Fire Damage www.minnehahacxeekora <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: v <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: Date: (5151,j <br /> :°Rese� �m <br />