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11/07/2011 15:03 9524738080 DALBEC ROOFING PAGE 02/03 , City of Orono Building Permit Application for Maintenance 1 Renovation (windows, doors, siding, re-roof, etc.) dt. Mailing Address. Permit number s--- C)//-/-)/ 7 ? /G Box 66 0 O '•' 1 Crystal Bay, MN 55323-0066 Date received: //- 7-//, "' Received by: Street Address: 1, ' ,,•,°j 7p3 2750 Kelley Parkway Plan review fee: ...114.!.'l'i.,‘\• Orono, MN 55356 Total Fee: ___"58- DO Main: 952-249.4600 Fax: 952-249-4616 www.ci.orono.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: 3 jQ W/� A L Job Site Address: . WIII this be a Parade of Homes, Remodelers Showcase Home or other Display Home? LfYes Zit p if yes,a special event permit is required with Police Department and City Council approval 80 days prior to the event, Shuttle bus cervica will be required unless applicant demonstrates sufficient on-site parking le svailablo, Non permitted avenlc will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: ` : - • State License# tij i p, Expiration Date: Mji1,.. Lead Certification Number: gip, Expiration Date: (for work on homes that were constructed prior to 1978 Phone: -.,$ -4 3-:,-'$O (office) Lo/p - 34. - . /31 (cell) Mailing Address: 02g28�, (' IAI IIEL s S-T, City: ,,:,,,i. 4 k ZIP: 515-351- Contact Person: JLl4 I C - o 2 Applicant is: on / Homeowner (circle one) E �E.P � Email and/or Fax: •u. Lxc...r l3... C 4 tvt P-Caac i' °2-473 •pe 0 --- PROPERTY OWNER INFORMATION: Name; C1_1 Fr l)77E/J Phone(day): 95a- 41-73- s-tas- Address: 73s_ WAyzATA 43t. City:4 ii, SAKE ZIP: 5-535 4, Email and/or Fax .. PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits: ❑Door(s) 0 Remodel ❑ Fire Damage MinnPhehn Creek Watershed District(MCWD) ❑ Re-roof,asphalt , Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑Re-roof,cedar ❑Restoration 0 Water Damage Phone: 952-471-0590 KRe-roof, other(specify) ❑Siding ❑Other. (specify) Fax: 952-471-0682 www.minnehahacreck.ore FAr EPnn ez-RaoF ❑Window(s) Overall Project Description:- E.E Afi FED •� p!= c \ j'oRK- Estimated Construction Valuation of Project(excluding land) $ 3y1, /> O 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 Information is to annually update our records and records of other governmental agencies re•uired b law. If ou refuse to su..l theinformationthe a.'lication ma not be issued. Applicant's Signature: -u eirm ,r (?'� ►-L) Date: /�- 7-/I Last Updated: 08-00-2011 (/ �_ �L 0 1- j_ 1 r= N" 175 c