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2912 Of./26 06:06 FAX 7635461068 ROOF'S PLUS IM 001/001 city of Orono Building Permit Application for Maintenance I Renovation (windows, doors, sidings re-roof, etc. Mailing Address- Pernnit number 62b/a• O sv0 PO Box 66 •r Crystal gay,MN 56329-0066 Date received: Street Addrew.' Recened by. 2750 Kelley Parkway Plan review fee: Orono.MN 55356 Total Fee: Main: 962-249.4600 Fax: 952-240-4616 www.ei.orono.mUj& This application form must be completed In full and all required Information must be submitted*+ a o-6 GENERAL INFORMATION: �� C..a,,. Incomplete applications will be rstamed. (Please print) ` Job Site Address: a 7t?S f1lsz�r$ Will this be a Parade of Homes,Remodelers Showcase Home or o9or Display Home? Yes No ff yes,a spedal amt permit is required wilt Poke Deparbnent and City Council approval W days prior to the event ShuMle bus sernnce wNl be moomd unbss @~demonstrates sutgdwe on-00 padang/s avaflaWe. Non-pemntNed events WN not be allowed. CONTRACTORTAPPIJT-11+ ORM�AT�ON: Name: =� k State License# �(�,_ el 9-.(.- Expiration Date: Lead Certification Number: &/q-r — 112R 56 1 Expiration Date: •- (for weor*on homes that were eonsruotod prior to 1978 (Coll) Phone: 17 IV Mailing Address: City. ZIP: S Contact Person: a. Applicant is: ZtnV / Hdrneowner (cna.5m) Email and/or Fax: S 4LZ A A7Z, T PROPERTY OWNER INF RMATION: Name: i G r Phone(day): C ZIP: Address: s a. C S c� �`7`• r Email and/or Fax PROJECT INFORMATION: Type Of Project: laity earth moventelit may require ❑Dow(s) [I Remodel El Fire Damage MCWD��8 permits: Mlnnehaha Creek Watershed District(Mf:WD) Do Re-roof asphalt ❑Repair IM storm Damage 18202 Minnetonka Blvd ❑Re-roof,cedar ®Restoration ❑Water Damage Deephaven,MN 55391 Phone: 952-471-0590 ❑Re-roof other(speelty) ❑Siding ❑Other,(specify) Fax: 952-471-0682 -_ ❑Windows) www.minnehahacmek&M _ Overall Project Dowd on: 4, Eadmated Construction Valuation of Proeat excludin land $ 134 gaa2g APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Bulkliing Deparlment; • Certifies that the information supplied is true and correct to the best of hisltror knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do to,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 confidendel. Private data is informsdon which generally cannot be given to the public but can be given to the subject•of the data. Confidential data is kdbrmatlon which generally cannot be given to elther the public or the subject of die data. Our purpose and intended use of t)h Information is to annually update our g and records of other governmental agencies required by law.,if vou refine/lo.supoN the' may not be Issued. Applicant's Signature: aAA2Date: 'ma l e, Last Updated: 0il-09.2011