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Jun 29 01 09:18p Anchor Roofing&Exterior 651-493-4527 p.2 City of Orono Building Permit Application for Maintenance/Replacement 1 Remodel — Residential ONLY .-<,�n s�Z),ns,�(rw�-::u C n..��'ru,ti.f [��tti� ehw — LC� yS9t'-'"",;.�F~'j../��P '^vtp 1Rl G..r'". �) � s-, : E �OO Mailing Address: PO Box 66 FPer-.mit number: 7i4 Crystal Bay,MN 55323-0066 received: _/ y Street Address: Received by: 2750 Kelley Parkway Orono,MN 55356 Plan review fee: 65 H DE's Main: 952-249-4600 Fax: 952-249-4696 www.ci.orono.mn.us Total Fee: X70. 6 8 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: ►l Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No Jf yes,a special event permit is required with Police Department and City Council approval 60 days actor to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wig not be allowed. CONTRACTOR/7PLICANT INFORMATION: Name: dlZfi/G2 , aQ00.�"%/Iz 1 � rQ%, State License# �' Expiration Date: Lead Certification Number: ya tyi_ Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) f X060- (office) Mailing Address: �} Cit ZIP: ntractor ,/ Email and/or Fax: Contact Person: _ �� !t! Applicant is: CoHomeowner (Girde One) :SZ-- PROPERTY OWNER INFORMATION: Name: R)6#01,0 MseAoq Phone(day): 7 , Address: City-e © ZIP: J� Email and/or Fax: h PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require [IDoor(s) Remodel ElFire Damage MCWD review&permits: j2(Re-roof,asphalt ElRepair ElStorm Damage Minnehaha Creek Watershed District(MCWD) ❑Re-roof,cedar El Restoration ElWater Dama 15320 Minnetonka Blvd Minnetonka,MN 55345 ❑Re-roof:other(spec7fy) E]Siding F7Other: (specify) Phone: 952-471-0590 ❑Window(s) Fax: 952-471-0682 nnr.minnehahacree_ k.orr Estimated Construction Valuation of Project(excluding land) $ 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 infomiati n is to annually upda a our records and records of other governmental agencies required by law, if you refuse to su I the inf imation,the a i ti ma not be issued. Applicant's Signat c� Date: 1 / Z6'/6 Owner's Signature: Date: Last Updated:January 2016