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2012 Oi/26 06:06 FAX 7635461068 ROOF'S PLUS [A 00 1/00 1 <br /> city of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc. <br /> Marling Address- Permit number <br /> O,¢p,A,O Box 66 <br /> Cr <br /> •r Crystal Bay,MN 55323.0066 Data received: <br /> Sheat Address: Received by <br /> 2750 Kelley Parkway Plan review,fee: <br /> Orono.MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.cus Total Fee:i.orono.mn. <br /> This application form must be completed In full and all required Information must be submitted.+ O <br /> GENERAL INFORMATION: oZ` o- <br /> Incomplete applications will be natured. (Please punt) l <br /> Job Site Address: a 7q5 1��es m!A 67 <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Dlsplay Home? El Yes No <br /> W yea,a special event penult Is required with pok&DepWbnent and City Council approval W days prior to the eHant Shuffle bus Servroe wal be <br /> tegw w unbu eppllcent&mommies rAgdeni ort-do parking/s avaft*. Non-psnmfNad events will not be allowed. <br /> CONTRACTORI-APPU T4NFORMAT ON: _. .. <br /> Name: r _ P1 k S nC✓ <br /> State License# a f Expiration Date: lia <br /> Lead Certification Number: &/q-T — /Dpi 15(a3_-- I <br /> Expiration Date: •- <br /> (for work on homes awt wen constructed pdw to 1878 (Coll) <br /> Phone: �a 7 7 _(. ... ) <br /> Mailing Address: City: ZIP: S <br /> Contact Person' Applicant is: ZfntracW / Hdmeowner (chile oke) <br /> Email and/or Fax: r S -r- <br /> PROPERTY <br /> PROPERTY OWNER INF? TION: <br /> Name, , G I' <br /> Phone(day): 7 5 Q— f/- <br /> Address: SCML C S 11 Grp• City: jor,9110 ZIP: ' 1 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> TYPa Of Proms Any earth movement may require <br /> MC <br /> 13Door(s) ❑Remodel El Fire Damage Creek <br /> 3� : <br /> Minnehaha Crreels Watershed District(MCWD) <br /> Do Re.roof,asphalt ❑Repair Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ®Restoration ❑Water Damage Deaphaven,MN 55391 <br /> Phone: 952-471-0590 <br /> O Re-roof,other(spedy) 0 Siding ❑Other.(specify) Fax: 952.471-0682 <br /> ❑W'ndow(s) wmw.minnehahacreek,RM <br /> Ovemll Project Descliptlon: �i� T� <br /> +Estimated Construction Valuation of Project excludin land $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all informatbn required or requested by ft Building Department; <br /> a Certifies that the informatlon supplied is true and correct to the best of hislher knowledge. The applicant recognRss 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 Stats lava as either private or <br /> confidential. Private data is informetfon 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 afiher the public or the subject of the data. Our <br /> purpose and intended use of FIs Information is to annually update our reoorda and records of other governmental agencies <br /> required by law.,ff vou refinallo.suWy the inform e a lication may not be Issued. <br /> Applicant's Signature: Date: Tcsrie tilos o�/oZ <br /> Last Updated: 09.09.2011 <br />